NACOSCE

AComprehens
iveRevi
ew
⇥⇤
⌅⇧⌃⌥ ⇤
⌃⇤⌦
Co
pyr
ight@ 2011,
Cana
dapr
ep.

Al
lri
ght
sre
ser
ved.
Nopa
rto
fthi
spubl
ic
ati
onma
yber
epr
oduc
edo
rtr
ans
mit
tedi
nanyf
ormo
rbya
ny
me
ans
,el
ect
roni
corme
cha
nic
al,
inc
ludi
ngpho
toc
opy
,re
cor
ding
,ora
nyi
nfo
rma
tio
nst
ora
gea
ndr
etr
iev
al
s
yst
em,
wit
houtpe
rmi
ss
ioni
nwr
it
ingf
romt
hepubl
is
her
.Re
pro
duc
ingpa
ssa
gesf
romt
hisbo
okwi
tho
uts
uch
wr
it
tenpe
rmi
ss
ioni
sani
nfr
ing
eme
nto
fco
pyr
ightl
aw.

Ca
reha
sbe
ent
ake
ntoc
onf
ir
mthea
ccur
acyo
fthei
nfo
rma
tio
npr
ese
nte
dandt
ode
scr
ibeg
ene
ral
lya
cce
pte
d
pr
act
ic
es.
Howe
ver
,thea
utho
rs,
edi
tor
s,a
ndpubl
is
her
sar
eno
tre
spo
nsi
blef
ore
rro
rso
romi
ss
ionso
rfo
rany
c
ons
eque
nce
sfr
oma
ppl
ic
ati
ono
fthei
nfo
rma
tio
nint
hisbo
oka
ndma
kenowa
rra
nty
,ex
pre
sse
dori
mpl
ie
d,
wi
thr
espe
ctt
othec
ont
ent
soft
hepubl
ic
ati
on.
Thea
utho
rs,
edi
tor
s,a
ndpubl
is
her
sha
vee
xer
tede
ver
yef
for
t
t
oens
uret
hatdr
ugs
ele
cti
ona
nddo
sag
ese
tfo
rthi
nthi
ste
xta
rei
nac
cor
danc
ewi
thc
urr
ent
r
eco
mme
nda
tio
nsa
ndpr
act
ic
eatt
het
imeo
fpubl
ic
ati
on.
Howe
ver
,i
nvi
ewo
fong
oingr
ese
arc
h,c
hang
esi
n
g
ove
rnme
ntr
egul
at
ions
,andt
hec
ons
tantf
lowo
finf
orma
tio
nre
lat
ingt
odr
ugt
her
apya
nddr
ugr
eac
ti
ons
,
t
her
eade
risur
gedt
oche
ckt
hepa
cka
gei
nse
rtf
ore
achdr
ugf
ora
nyc
hang
eini
ndi
cat
ionsa
nddo
sag
eand
f
ora
dde
dwa
rni
ngsa
ndpr
eca
uti
ons
.Thi
sispa
rti
cul
arl
yimpo
rta
ntwhe
nther
eco
mme
nde
dag
enti
sane
wor
i
nfr
eque
ntl
yempl
oye
ddr
ug.

Thi
spubl
ic
ati
onha
sno
tbe
ena
utho
red,
rev
iewe
dors
uppo
rte
dbyt
heMe
dic
alCo
unc
ilo
fCa
nada
,no
risi
t
e
ndo
rse
dbyt
heMe
dic
alCo
unc
ila
sar
evi
ewma
ter
ialf
ort
heNACOSCE.
 ⇥⇤⌅⇧⌃⇤

Thi
sbo
okwa
swr
it
tenduet
othel
acko
fpr
epa
rat
ionma
ter
iala
vai
la
blef
ort
heNa
tio
nalAs
ses
sme
nt
Co
lla
bor
ati
on(
NAC)Obj
ect
iveSt
ruc
tur
edCl
ini
calEx
ami
nat
ion(
OSCE)
.Asa
nInt
erna
tio
nalMe
dic
al
Gr
adua
te(
IMG)pr
epa
ringf
orc
li
nic
ala
ndwr
it
tene
xamsi
nCa
nada
,the
rei
snoc
ompr
ehe
nsi
ver
evi
ew
t
ext
boo
kav
ail
abl
efo
rtheNACOSCE.
Duet
othi
sla
cko
fre
sour
cema
ter
ial
s,ma
nys
tude
ntsa
ref
orc
edt
o
s
tudyf
roms
our
cest
hata
reno
tre
lev
antt
otheNACOSCEe
xam.
Thi
sev
ent
ual
lyha
mpe
rst
hec
andi
dat
e'
s
c
hanc
eso
fag
oods
cor
eint
hee
xami
nat
ion.

Thi
sbo
oka
imst
ogui
dey
out
hro
ught
hes
tepso
ftheNACOSCEa
nde
nsur
etha
tyo
uar
ewe
llpr
epa
red
a
ndas
tepa
hea
doft
hec
ompe
tit
ion.Ag
rea
tef
for
tha
sbe
enputi
ntoc
oll
ect
inga
ndo
rga
niz
ingr
el
eva
nt
c
ont
entf
orbo
tht
hec
li
nic
alOSCEs
tat
ionsa
ndt
hewr
it
tent
her
ape
uti
cex
am.
Wr
it
tenb
yme
dic
alg
radua
teswhoa
reo
rie
nte
dtot
heNACOSCE,
thi
sco
mpr
ehe
nsi
ver
evi
ewc
anbeus
ed
a
saf
rame
wor
k,c
ompl
eme
nti
ngy
ourc
li
nic
als
kil
lsa
ndt
her
ape
uti
ckno
wle
dgea
syo
upr
epa
ref
ort
he
e
xami
nat
ion.

Thi
sbo
oki
sde
dic
ate
dtoa
llt
heI
MGspr
epa
ringf
ort
heme
dic
all
ic
ens
inge
xami
nat
ionsi
nCa
nada
.

“
Andmo
sti
mpo
rta
nt,
havet
hec
our
aget
ofo
ll
owy
ourh
ear
tandi
ntu
iti
on.
The
yso
meh
owa
lre
adyk
nowwh
aty
ou
t
rul
ywa
ntt
obe
come
.Eve
ryt
hinge
ls
eiss
ec
ond
ary
.”-St
eveJ
obs
Th
isi
sab
lankp
age
 ⌥⇧ ⇤⌦
↵⌅⌦
⌃↵ ⌥⇤ ⌥

Intr
oduc tiont oNACOSCE
Ge ne ralI nf orma tion. .
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1
Re g istr
a tio nf o rNACOSCE. .
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1
Fe e s. .
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1
Ex ami na tions ta t
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1
NACOSCEs coring. ..
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2
Sa mpl eo fThe rapeut i
cwr ittent es
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2
Sa mpl ec lini calc ases tat
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3
The r
apeut icGui de line s
Me dic
ine
Ca r diolo gy. ..
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7
De rma t olo gy. .
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11
Endo crino l
o gy. .
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14
Ga stroe nt ero logy. ...
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16
He ma t
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19
Infe ctio usDi sea s
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19
Ne ur o l
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21
Ot o lary ng o l
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23
Pul mo no logy. ..
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24
Rhe uma tolo gy. ...
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26
Ne phr olo gy /Ur ology. ..
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29
Eme rge nc yMe dicine. .
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30
Co uns eling( s mo k i
ng /alcoho l)..
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35
Obs t
etri
c s& Gy ne c ology
Se xua llyt r ans mi tt
e dinfe c
tio ns...
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38
Ur ina ryt racti nf ection....
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39
Vul v ova g initis. ..
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39
Pe lvici nf lamma t
or ydi s
ease. ..
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40
Dy sfunc tiona lut erinebl eeding. ..
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40
Dy sme no r r
he a. .
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40
Endo me trios is...
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40
Ho rmo ner e pla ceme ntt herapy. .
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41
Eme rge nc yc ont raception......
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41
Gr o upBSt rept oco ccusinpr egnancy..
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41
Pre g nanc yi nduc edhy pertens i
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41
Ec to picpr e gna nc y. .
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42
Hy pe reme sisg ravidarum . .
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42
Dr ug sc o ntra indic atedinpr e gnancy...
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42
Pediat
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Ac ut eo titisme dia...
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As thma. .
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45
Ba ct erialt rac he it
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45
Ba ct erialpne umo nia. .
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46
Cr o up( La ryng o tr
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48
Epi g lottitis. ...
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48
Stre pto co c calpha ryng it
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48
Who opi ngc o ug h( Pertussis)...
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48
Ba ct erialme ning itis...
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49
Fe br il
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49
Ur ina ryt racti nf ection....
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49
Al lerg i
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50
Ane mi a. .
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50
Do seo ft yleno l...
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50
Immuni z atio ns che dule. .
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50
 ⌥⇧ ⇤⌦
↵⌅⌦
⌃↵ ⌥⇤ ⌥
Ps
ychi
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De le rium . .....
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52
Ma nia. ..
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53
Pa nicdi so rde r....
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53
So cialpho bi a.....
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54
Ge ne r ala nx ietydi s
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54
Obs es sivec o mpul si
v edi sorder. .
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55
Po stt ra uma tics tr
e ssdiso rder. .
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55
De me nt ia. ...
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55
De pr e ssion. .
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56
Psy cho sis.....
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56
Mo o ds tabilize rs...
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57
Me dic at i
o nsc a usings exua ldysfuncti
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58
Sub s tanc ea bus e....
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59
Cl
inic
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Abdo mi na le xa mi nation. ....
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63
Ca rdi ov ascul are xa mi nation. .
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65
Per i
phe r alv ascul arex ami na t
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67
Re spir ato rye x ami na ti
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69
Ce nt ralne rv ouss y s
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71
Uppe rl imbne uro l
o gicale xami nati
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73
Lo we rl imbne ur ologicale x a
mi nation...
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75
Mus co lo -ske letals ystem: Spine /Back...
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77
Hi p. .....
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79
Kne e. ..
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81
Foo ta nda nk le. ..
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83
Sho ul de r. .
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85
Elbo w. .
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87
Ha nda ndwr ist. .
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88
Bre aste xami na ti
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90
Thy roid. .
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91
Mi niMe nt alSt at
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93
Cl
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99
Medici
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103
Co ng e stivehe a rtfailure. .
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104
Ce rebr ov a scula rattac k....
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105
Di go xint ox ici
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106
Infec tio usmo no nuc leosis( sor
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107
Impo te nc e. ..
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108
Me ning iti
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109
He a da che( mi g raine). .
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110
Che stpa in( My ocardialI nf a
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111
Pne umo ni a. .
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112
Pos te x po sur epr ophy l
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113
Pul mo na rye mbo lis
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114
Seiz uredi so rde r....
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115
Tempo rala rteritis...
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116
Vir alhe pa titi
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117
Obste
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118
Ant e na talv isit. .
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119
Ec topi cpr eg na ncy. .
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120
 ⌥⇧ ⇤⌦
↵⌅⌦
⌃↵ ⌥⇤ ⌥
Infertility. ...
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.121
OCPc o uns eling. .
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.122
Pelvici nf lamma torydi sea
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.123
Place nt apr evia. ..
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.124
Pree c l
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.125
Pedi
atri
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Failuret ot hr ive. ..
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.126
Febr i
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.127
Me a sles. ....
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.128
Ne ona ta lja undi ce.....
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.129
Prima ryno ctur nale nur e
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.130
Pylo rics te no sis. .
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.131
Spe echde lay. ....
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.132
Psyc
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.133
Bulimi a. ..
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.134
De l
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.135
De me nt i
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.136
De pre ssio n. ...
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.137
Ma ni a. ...
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.138
Pani ca tta ck. ....
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.139
Schi zo phr e nia. ...
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.140
Suicide. ....
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.141
Surge
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.142
Basa lc ellc a r
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.143
Beni gnpr o st
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.144
Ca rpa lTunne lSy ndr ome. ..
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.145
De epVe inThr o mbo si
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.146
Dia be ticf o ot. .
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.147
Difficul tys wa llowi ng( Cao esophagus)..
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.148
He ma teme si
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.149
Ne cks we lling. ..
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.150
Paina bdo me n. ...
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.151
Periphe ralv a
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.152
Posto pe rat iv
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.153
Solitaryl ungno dule. .
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.154
Thy ro idma s
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.155
Trauma. .
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.156
Counsel
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.159
Chi lda bus e. ...
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.160
Do me sticv iolenc e. ..
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.161
Ho rmo ner epla ceme nttherapy..
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.161
Ma mmo g ram. ....
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.163
Immuni zatio n. ...
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.164
Obe si
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.165
Smo king. ....
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.167
Th
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sab
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Quest
ion:
Ano therwis
ehea
lthy65y e
aroldwo manpre
sentswitha3weekhi
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ryofachi
ng
a
ndmo rni
ngsti
ffnes
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cul
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ate
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sisofPOLYMYALGI ARHEUMATI CA( PMP).
Whatwo
uldyouchooseast
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cefo
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ti
alme
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ug,
dos
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r
out
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nis
tra
tio
na nddur
ati
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erequir
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)
Ans
wer
:________________________________________________________
Ans
werk
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hema
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rre
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ves
:
PREDNISONE7.
5–20mgPO o
dfo
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eksf
oll
owi
ngr
eso
lut
iono
f
sy
mpto
ms

Quest
ion:
Ano therwis
ehealt
hy55yearoldmalewit
hshis
toryofc
hil
dhood“chi
cke
npo
x”
pr
ese
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eadiagnosi
sofHERPESZOSTER( s
hingl
es)
.
Whatwouldy
o uc
hoos
ea st
hedrugoff
ir
stchoi
cetopr
omoteheal
ingandle
ssent
he
ne
uro
pat
hicpa
in?(
Drug,dos
e,r
outeo
fadminis
tra
tio
nanddura
tio
na rer
equi
red.
)
Ans
wer
:___________________________________________________________
Ans
werk
eyt
hema
rke
rre
cei
ves
:
VALACYCLOVI
R(VALTREX®)1000mgPO t
idX7da
ysOR
FAMCI
CLOVI
R(FAMVI
R®)500-750mgPO t
idX7da
ysOR
ACYCLOVI
R(ZORI
VAX®)800mgPO 5X/da
yX7da
ys)
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ampl
eins
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ti
onwr
it
teno
uts
idet
hes
tat
ion

Da
vidTho
mps
on,
59y
ear
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d,pr
ese
ntst
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ai
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ert
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ampl
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sti
ons

Q1.
Thea bdomina
lexa
minat
ionofDavi
dThompso
nreve
alednoorg
anenl
arg
ement,
nomas
sesandno
tendernes
s.Whatr
adi
olo
gici
nves
ti
gati
onwo
uldyo
ufirs
torde
rtohe
lpdis
cri
mina
tet
hec
auseofthe
jaundi
c e
?

Q2.
Ifthei
nve
sti
gat
ionsrev
eal
edthatthi
spat
ientl
ike
lyha
dapo
st-
hepa
tico
bst
ruc
ti
on,
wha
tar
e
thetwopr
inci
paldia
gnost
icc
o ns
ider
ati
ons
?

Q3.
Wha tra
diol
ogi
cpr
oce
dur
ewo
uldy
ouc
ons
ide
rtoe
luc
ida
tet
hel
eve
landna
tur
eoft
he
ob
str
ucti
on?
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isi
sab
lankp
age
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apeut
icGui
del
ines
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isi
sab
lankp
age
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At
ri
alFi
bri
ll
ati
on
1. Tocont
rolr
a te:
• I njMe toprolol5mgbo lusIV, foll
owe dbyi nfusi
ona t0.05mg /
kg/mi n,i
ncr
e a
singasneeded
to0.2mg /
k g/mi n.
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tiaz
e m 20mgbo l
us .Ma intenanceinfusionof5- 15mg /
hr.
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apami l5- 10mgI Vov er2- 3mi n,repeatedonc eaft
e r30mi ns.
• Ta bAmi odaro ne( i
nc aseo fhe artfail
ure)
:
• Lo adingdo se:800–1600mgPO i ndivi
deddo s
esunt i
lresponse
;til
lma x1000
mg /daydi v
idedbi d-tid.
• Ma intenanc e
:200mgPO o d.
2. Toprev
entthrombo embo li
sm: As s
esswi thCHADS2s core
• Nor isk:TabAs pir
in81- 325mgPO o d.
• 1mo derat
er i
sk :TabAs pirin81- 325mgPO o dorTa bWa rf
ari
n2- 15mgPO o dtoma int
ain
INR2- 3.
• >1mo de r
ater i
sko rveryhi ghr i
s k
:Ta bWa r f
arin2-15mgPO o dt oma i
ntai
nI NR2- 3.
3. Tocont
rolr
hy thm:
• Ta bFl ecai
nide300- 400mgPO bo lusdose,ma int
ena nce:50-150mgPO bi d.(Fi
rstcho
ice)
• Ta bSo talol80- 160mgPO bi d. (Secondc ho i
ce)
• Ta bAmi odaro ne( i
nc aseo fhe artfail
ure)
:
• Lo adingdo se:800–1600mgPO i ndivi
deddo s
esunt i
lresponse
;til
lma x1000
mg /daydi v
idedbi d-tid.
• Ma intenanc e
:200mgPO o d.
• El ectri
calCa rdioversi
on: 100-360j ou l
es.

Cong
est
iveCa
rdi
acFa
il
ure:
Imme
dia
tema
nag
eme
nti
ntheER 3⌦ $⇠⇣ $&⇣↵$⌦ &↵⇣& ↵
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Nonpha
rma c
ologicalma nagementofHe a
rtFa i
lure
• Exe r
cis
e: Regularphy s
icala ct
ivi
ty
• Saltres
tri
ction:s ymptoma ticHF–2- 3gs a
lt/
day(Ttsp/
day)noadde
dsalti
ndiet
.
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tent
ion: 1-2gsal
t/
day(Utsp/da
y)
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ientswithfl
uidre
tent
ionorHFno tc
ontr
oll
edbydi
ure
tic
s.
• Da i
lywe i
ghtme asur
eme nt.
• Educ at
ion.
• Ag gr
essiv
er i
skre duct
ion( BP ,g
lucos
e ,
lipi
ds).
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tylemo dif
icatio
ns,influenzavacci
na t
ion.
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Dy
sli
pide
mia

1. HMG Co AInhibit
o rs:
• At orvas
tati
n: TabLi pitor10-80mgqhs
• Ro s
uvast
atin: Ta bCr est
or10- 40
mgqhs
• S/ E:GIs ympt oms,rash,pruri
tus,
inc
reas
edli
verenz
yme
s,my
osi
ti
s.
• C/ I:act
iveliverdisease,mus c
ledis
eas
e,pre
gnancy
.
2. Fi
brat
es:i
ncrea
sedTG
• Fe nofi
brate: TabLi pidil67-200mg /
d
3. Bi
leaci
dsequest
rants: increa
sedLDL
• Ta bCo les
tipo l5-30g/da y
4. Chole
ste
rolabs
orptioni nhibit
o rs
:
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mi be10 mg/ day.

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per
tens
ion

Nonpha
rma
col
ogi
cal
tre
atme
nt:

• Smok i
ngc e
ssat
ion:s
mo k
ingaggr
avat
eshypert
ens
ionandremainst
hema j
orcont
ri
butort
o
ca
rdiovas
cula
rdisea
seinpeopl
eunder65years
.
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ghtreduct
ion:Ma i
ntai
nBMI <27,pa
rti
cul
arl
yinpati
entswit
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um restr
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ion<150mmo l
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y.

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Bur
ns

• Init
ialas
sessmentofABCs, consi
derthene edfore a
rlyintubat
ionifai
rwayiscompromis
ed.
• Humi dif
iedO2i fanys us
pici
onf ori
nha l
ati
onalinjury.
• Ox ygen100%i fknownc arbonmo noxideexposureo ffir
einane ncl
osedspace
.(Hal
fli
feof
hemo gl
obinwi l
ldropfrom 330to90mi ns)
.
• Establi
shIVa cces
s.
• Fluidres
uscita
tio
n: Parkl
andf or
mula4mL/ kg/%BSAbur n,Tover8ho ur
sandres
tover16hour
s
• Na s
o ga
str
ictubedrainageforil
eus.
• Bladdercathet
eri
zati
o ntomo nit
oruri
na ryoutput,mi nimum 1mL/ kg
/hr.
• Tetanusprophylax
is:0.5mLt e
tanustoxoidIMi npr e v
iousl
yimmuni z
eda nd250uni
tsTIGI Mif
unimmuni zed.
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Ps
ori
asi
s

Topi
cal
Pre
par
ati
ons:

1.Topica
lCo rtic
o st
e roids:
• Hi ghPo t enc yTopi calStero
ids( Us uall
yindicat
ed)
• Ve ryhi ghpo tency:e.g.Cl obetas
ol(Temov a
te)
• Hi g hpo tency:e.
g .Fluo ci
no ni
de( Lidex)
• Lo wPo tenc yTopi calSteroi
ds
• Fa ce
• Ge nit
als
• Ma intenanceThe r
apy
2.Vit
ami nD b asedt opi cal
s:
• Ca lc
ipo t
r i
e ne(Dov onex)
• Us edinc ombi na t
ionwi thTo picalCo r
tic
ostero
ids
3.Reti
noidba sedt opica l
s:
• Ta z ar
o tene( Ta zorac)
• Mo r
ei rr
itat i
ngt hanCa lc
ipotriene
4.Immuno suppressantba sedto pica
ls:
• Ta c r
olimus0. 1%o rPi mecroli
mus0. 1 %creams
Effectiveinf ac
ialandi ntertri
gino usPs or
iasi
s
5.Adjuncti
vea gentsinc ombi nationwi t
ha b ove:
• To pic
a lSa licyl
icAc id(Ke ratol
y ti
cAg ent
)
6.Poorl
ytoleratedto pic al
s(useCa l
cipotri
e neins t
ead):
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orica l
lyus edwi t
hUVBl i
g hte xposure
• Ant hrali
n( Ant hra-De rm)
• Co alTa r(e .g.Ze t
ar)

Ul
tr
avi
ole
tli
ght

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skofnon-Melanomaskincance
r
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otoc
ols
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ravi
oletBexpos
urealone
• Ul t
ravi
oletAexposur
ewithpsora
len(
PUVA)
Incr
easedr
iskofnon-Me l
anomaski
nca
nce
r

Sy
ste
mica
gent
s(mos
tar
eforhi
ghe
rri
sk)

• I
mmuno
suppress
ants
• Etreti
nate
• Cy c
lospori
ne
• Me thotr
exat
e(unc
lea
ref
fi
cac
y)
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• Bi
ologi
calagents
• Tumo rnecrosisfact
o r(TNF)receptorbl
ockers
Et anerce
pt( Enbr el
)
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ima b(Re mi c
ade)
• Ot herme chanisms
Al e
f a
cept( Ame vive)
Ef a
lizuma b(Ra pti
va)
• Thi
a z
oli
dinedione( Avandia,Ac to
s)-experi
me nt
al
• Appe arseffect
iveinPs oria
sise
veninno n-di
abet
ic
s
• Onl ysma lltr
ialssuppo r
ttodate

Ce
ll
uli
ti
s

• Caus
e:β Hemo
lyti
cStreptoc
occus,St
aphy
lococ
cus
• Tr
eat
ment: TabClox a
cil
li
n500mgPO qidx10-14days
Ifpa
tie
nti sal
le
rgi
ctopeni
cil
li
n:TabCephal
exi
n500mgPO qi
d10-
14da
ysOR
TabClindamycin300mgPO qidx10-
14days

Pe
dic
ulos
is

• Perme thri
n1%-wa shhairwithreg
ularsha
mpoo,t
henappl
yper
methri
nandle
avefor10mi
nst
hen
ri
nse
• Pyrethrinswithpi
peronylbutoxi
de
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,youngchil
dre
nandpreg
nantwomen,
cause
sneur
otox
ici
ty
• Wa sha llcl
othesa
ndlineninho twate
r,t
henmachi
nedry.

Sc
abi
es

• Pe
rmethri
n5%-ma ssagei
ntoal
lsk
ina r
e a
s,f
romthet
opo ft
hehe
adt
othes
ole
soft
hef
eet
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avef
or
8-
14ho ur
sthenwa s
ho f
f.
• Crot
amito
n10%
• Sc
abene(aer
osols
pray)Esdepa
ll
et
hrin
• Li
ndane:usedonlyifal
ler
gict
opermethri
n.
• Tr
eatfa
milyandcontact
s.
• Washallc
lot
hesandl i
neninhotwate
r,thenmachi
nedry
.

Ti
neaCr
uri
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dis(
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Appr
oac
htoma
nag
eme
ntofdi
abe
tesme
ll
it
us

1. Lif
est
ylemo difi
ca t
ion& patienteducat
ion
2. Oralhypoglyc
e micmo no t
herapy:
• Bi g uanides(Me tf
ormi n)–250-500mgPO bid-
ti
d( i
fobeseorov
erwei
ght)
• Sul f
ony l
ureas(Glyburide)–80mgPO bi d
• Thi azoli
dinedione(Pio gl
it
azo
ne)–15mgPO o d;Rosi
gli
tazo
ne–4 mgPO od
• Al phag lucosi
daseinhibit
ors(
Ac ar
bose
)–50 mgPO ti
d
3. Oralco
mbi nationtherapy(2a gentsof
tenneede
d;aft
er3yea
rs50%,aft
er9yea
rs75%)
4. Ins
uli
nt he
rapy+/ -o r
alhypo gl
y c
emics

Di
abe
ticKe
toa
cidos
isMa
nag
eme
nt

• Fluidrepla
c eme nt
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e1l i
terNSbo lusove rfi
rst45mi nutes,
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uidbo lusunti
lshockco r
rect
ed.
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rs
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ineorLa c
tated
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rs.Replacere maini
ng50%de f
icitove rnext16ho urs,
us eD51/ 2NSa t150-250mlper
ho ur.
• Insuli
n( Hy pokalemiamus tbec or
re ct
edpr iortoI nsuli
n)
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i
. Gi veI Vbo l
usof0. 15uni ts
/kg
i
i.St ar
t0. 1uni t
s/kg/hourI nsuli
nDr ip
• Ma inte
na nce
i. Ant icipat
eSe rum Gl ucosedro po f50-70mg /
dl/hour
• I finadequa t
edr op,the nincreasedri
p
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b)Co ntinuea tincreasedrateuntiladequate
ii
. Whe nSe rum Gluc ose<200- 250mg /
dl
a) Ke epSerum Gl ucosea t150t o200mg /dl
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• Pot
assi
um
Dono tadmini s
terI
ns uli
nunt i
lpotassi
um >3.
3
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lcorrect
s
• Serum Pot
ass i
um 3.3to5. 0mEq/ L
i. St
anda rdreplacement:20-30mEqpe rl
it
er
• Serum Pot
ass i
um >5.0mEq/ L
i. Dono tadministeranypotassi
um
ii
.Mo nitorevery2ho ursuntil<5.0
• Bic
arbonat
e
Indic
ati
ons
i. ABG pH <6. 9t o7.0afte
ri ni
tia
lhourofhy
dra
tio
n
ii
.Ot he rcont
ributingfact
ors
• Sho cko rCo ma
• Se vereHy perk
alemi a

Hy
per
thy
roi
dis
m

• Ta
bPr opy
lthi
o ur
aci
l(PTU)100mgPO t id,
toma
x150mg6-
8ho
urs
.
• Ta
bMe t
himazo l
e10-30mgPO o d.
• Medic
ati
onsas so
cia
tedwit
hHy pert
hyr
oidis
m:
Exce
ssThy roi
dho r
moneint
ake
Diet
aryIodine
Amiodarone

Hy
pot
hyr
oidi
sm

• L-
Thyroxine0. 05-0.
2mg /da
y
• Medi
cati
onsa ss oci
atedwithHypo
thy
roi
dis
m:
i
. I norga niciodine
i
i.I odide
i
ii
.Ami o darone
i
v. Lithium

Hy
per
prol
act
ine
mia

• Ta
bBromocr
ipt
ine1.25-
2.5mgPO o
d,i
ncrea
seby2.
5mg/da
yq3-
7day
stomax15mg/
day
.
• Ta
bCaber
gol
ine0.25mgPO twic
eweek
ly,
ma yi
ncr
eas
eby0.
25mgq4wee
ksuptoma
x1mgtwi
ce
we
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y.
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Me
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nemi
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d) SSRI
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f) Va l
pr o
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d
g) Me t
hy ldopa
h) Ve rapami l
i) At enolo l
j) Da na z
o l
k) Es tr
o gen
l) De po -Provera
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n) Me t
o cl
o promide
o) Amphe tamines
p) Ca nna bis

I
mpot
enc
e

• TabSildenaf
il25-100mgperdose,t
ota
keha
lfa
nho
urt
o4ho
urspr
iort
oint
erc
our
se.
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lushing
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da c
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Appe
ndi
ci
ti
s

Per
ioper
ati
vefor24hr
s
• Inj
Ampi ci
ll
in1-2gIVq4-6h.
• Inj
Flagyl500mgIVbid.
• Inj
Ge nta
mi c
in3-5mg/k
g/dayq8h(
moni
torc
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tini
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ls)
.
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• Ta
bNo rf
loxa
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ys. ⌅
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utePa
ncr
eat
it
is

• NPO
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agy
l400mgIVq8h
• InjMeper
idi
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100
mgIVq2-
3h
• IVF
• NG tube
• Repla
cecalc
ium

Cr
ohn
’sDi
sea
se

1. Mi
ldt
omo der
ate:
• Ta bMe sal
ami ne800mgPO t i
d.Ma i
ntena
ncedos
e3. 2–4gperda y
.
• Ta bSulfa
sal
a zine250mgperdayandincre
aseupto2gpe rda
y.Ma int
ena
ncedosei
s500-
1000mgPO qi dwithfoo
d.
2. Mo
der
atetose
ve r
e:
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o ne40mgPO qi dx8-12we ek
sandtapergr
adual
ly.
• Ta bAza t
hioprine2-2.
5mg /
kg/da
y.Usedformai
ntenanc
ewhiletaperi
ngcor
ti
cos
ter
oids
.

Di
ver
ti
cul
it
is

• I
njFl
agy
l500mgIVbid.
• I
njCi
prof
lox
aci
n500mgIVbi
d.

He
li
coba
cte
rPy
lor
i

1. HP- PAC(
7bl
iste
rpa c
k)7-14day
s
• TabLansoprazol
e30mgPO bid+
• TabClari
thromyci
n500mgPO bid+
• TabAmo xici
ll
in1gbid
2. 2ndLI NEQua
druple:14days
• TabLansoprazol
e30mgPO bid
• TabFlagyl500mgPO bid
• TabTetra
cycli
ne500mgbid
• TabBismuth525mgPO qi d
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⌦
⌦⌦
⌦⌦
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⌦⌦
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⌦
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⌦⌦
⌦⌦
⌦
⌦⌦
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⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

He
pat
it
isBpos
tex
pos
urepr
ophy
lax
is

1. KnownHBs AgPos itiveSour ce:

i. Unvaccinatede xposedpa tient:
• He pa tit
isBI mmuno g l
o bulin(HBI G)0. 06ml /k
ga nd
• He pa tit
isBVa cc i
ne0, 1a nd6mo nths.
ii
. Exposedpa tientwithk no wnr espo nsetov a
c c
ine:
• Not reatment .
ii
i.Exposedpa tientwithk no wnf ai
le drespo nset ovacci
ne:
• Pa tienthasno ty etco mpl eteds econd3- doseseri
es:
• He pa ti
tisBI mmuno g l
o bulin(HBI G)0.06ml /
kgand
• He pa ti
tisBVa cc i
ne( compl etesecond3-do seser
ies
)
• Pa tienthasc ompl etedt wopr i
o r3- doseseri
es:
• He pa ti
tisBI mmuno g l
o bulin(HBI G)0.06ml /
kg
• Se co ndHe pa ti
tisBI mmuno g
lobuli
ndo se.
iv
. Exposedpa tientwithunk no wnr e sponset ov acci
ne:
• Te stforAnt ibo dyt oHBs Ag
• Ade quateAnt i
bo dy( HBs AgPo sit
ive):Not re
atme nt
• I na dequa t
eAnt ibo dy( HBs AgNe gativ
e)
• He pa ti
tisBI mmuno g l
o bulin(HBI G)0.06ml /
kgand
• He pa ti
tisBVa cc i
nebo osterdose:
2. KnownHBs AgNe ga tiv
eSour ce:
i. Admi nist
erHe pati
tisBVa ccineSe rie
si funv acci
nated
ii
. Notre a
tme nto therwisene ede d.
3. UnknownHBs AgSour ceSta t
us :
i. Unvaccinatede xposedpa tient
• He pa tit
isBVa cc i
neSe rie s
ii
. Exposedpa tientwithk no wnr espo nsetov a
c c
ine
• Not reatment
ii
i.Exposedpa tientwithk no wnf ai
le drespo nset ovacci
ne
• Tr eatsourcea sHBs Agpo sit
ivei fhighrisk
iv
. Exposedpa tientwithunk no wnr e sponset ov acci
ne
• Te stforAnt ibo dyt oHBs Ag
• Ade quateAnt i
bo dy( HBs AgPo si
tive)
:Not reat
me nt
• I na dequa t
eAnt ibo dy( HBs AgNe gativ
e)
• He pa ti
tisBVa cc i
nei nitia
la ndboosterdo se
• Re che ckt it
eri n1t o2mo nths
4. Inf
antwi
thHBs AgPos it
iveMot her:
i. Hepatiti
sBI mmuno glo bulin( HBI G)0. 5mlwi t
hin12ho ursofbir
th.
ii
. Hepatiti
sBv accine:Do se1wi thin12ho urso fbirt
h,Do se2a tage1mo nt
hs,
Dos
e3a
tag
e
6mo nths.
ii
i.RepeatHBs Aga ndHbs Aba t9mo nths& 15mo nths.
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|&✓⌃ ⇥✓ =

Pe
pti
cul
cerdi
sea
se

• Ta
bOmepra
zol
e20mgPO od.
• Ta
bRa
nit
idi
ne150mgPO bid.

Ul
cer
ati
veCol
it
is

• Ta
bSulfasa
laz
ine250mgpe rdayandincr
eas
eupto2gperda
y.Maint
ena
ncedo
sei
s500-
1000mg
PO qi
dwithfood.
• Ta
bMe s
ala
mine800mgPO t id.Mainte
nancedo
se3.
2–4gperda
y.
• Rec
tals
upposi
tori
espr
efe
rre
df orpro
cti
ti
s.

Ac
uteChol
ecy
sti
ti
s(Pe
rio
per
ati
ve)

• I
njCef
azo
lin0.
5-1.
5mgI
Vq6h
• NPO
• I
VF
• NGTube

0(
⌦3✓⌫◆⇤
⇧⇧⇡)

Ane
mia

• Iro
nDe f
ici
encyAnemia:TabFe r
rousfuma
rate
(Pal
af
er)300mgPO qdOR
TabFerr
ousSulf
ate325mgPO qd
• Me ga
lobl
ast
icAnemia:TabFerrousFumar
ate300mgPO qd+TabFoli
cac
id1-
5mgPO qd+
InjB12100mgqmo nt
hlyor1000–2000microgr
am PO.

8(
⌦⇥✓ ⇤⇧⌥⇢
⌦*⇢
✓◆⇢
✓⇢

Pr
ophy
lax
isf
oroppor
tuni
st
ici
nfe
cti
onsi
nHI
Vpa
tie
nts

• Pne
umo cy
sti
scarinii
:CD4c ount
<200c el
ls/
mm3o rora lcandidias
is
.
• Ta bTMP/ SMZDSPO OD t il
lCD4c ountsr is
es.
• To xopl
asmag ondii
:IgGantibo
dypo sit
iveandCD4c o unt<100ce
ll
s/mm3
• Ta bTMP/ SMZDSPO OD t il
lCD4c ountsr is
es.
• Mycobac
ter
ium tuberculos
is
:Ma nto
ux>5mm i ni mmuno compr omise
dorcont
actwi
tha
cti
veTB.
• Ta bIsoniazid50mgPO OD x9mo nthsalongwi th
• Ta bPy r
ido xi
ne50mgPO OD.
• Mycobac
ter
ium avium complex:CD4c ounts<50c ell
s/mm3.
• Ta bAz i
thr o
my cin1200mgPO o nceawe ek.
• Ta bClarithromycin500mgPO o nceawe ek.
• Var
ice
ll
azoste
rvirus:Re c
entexpos
uretochickenpo xo rshingles.
• Va ri
cel
laz ost
erimmuneg lobul
inwithinZ96ho ursofe x
posur
e.
-⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
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⌦⌦
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⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

HI
Vpos
tex
pos
urepr
ophy
lax
is

• St
artwithi
nho urso fexposure(under24to4 8ho urs
).
• Tr
ipleTherapyf o
r4we eks:
1. Firsttwome dicat
ions:AZTa nd3TC( orCombivir
)
i. Ta bZi dovudine(AZT)300mgPO bi dand
ii. Ta bLa mi v
udine(3TC)150mgPO bi d.
2. Thi rdme dicat
ion( chooseone):
i. Ta bIndinav i
r(IDV)800mgPO t i
do r
ii. Ta bNe lfi
navir(Vir
acept)750mgPO t i
dor
iii
.Ta bEf avi
renz600mgPO qhs .
• Obtainbas
elinelabstomo nito
rforadvers
er ea
cti
o n:
1. Preg nancyTe s
t
2. Co mpl et
eBl oodCo untwithdiff
erent
ialandplat
ele
ts
3. Ur i
na l
ysis
4. Re nalFunc ti
onTe sts
5. LiverFunc tionTe st
s

Ma
lar
ia

1. Tr
eatmentfora
ctiv
ei nfect
ion:
i
. Ta bChlo r
o quine1gPO s t
at,
t he
n5 00mgPO 6-
8ho
ursl
at
er,
the
n500mgPO a
t24ho
urs
& 48ho ur
sa fteri
niti
aldo
se.
i
i. TabMe floquine1250mgs ta
tdo se.
i
ii
.Ta bPrima quine15mgba sePO o dx14days.
2. Chemoprophyl
axis
:
i
. Ta bChlo r
o quine500mgPO o nceaweek.
i
i. TabMe floquine250mgPO o nceawe e
k.

Pul
mona
ryt
ube
rcul
osi
s

1. Ini
ti
ati
onPhase:
TabRifa
mpin120mg+TabIs
oni
azi
d50mg+TabPyr
azi
namide300mgf
or2
months.
2. Conti
nuati
onPhase:
TabIso
nia
zid50mg+Ta
bRifa
mpin120mgf
or4months
.
3. AddTa bPyri
doxi
ne(Vi
tB6)50mgPO OD.

Ra
bie
s

Po
stex
pos
ureprophylaxi
s:
• Wa s
hwo undwi thsoa
pa ndwater
.
• Huma nRa biesImmunoglobul
in20IU/kgIMs t
atandha
lfdo
seint
othewound.
• Rabiesvac
cine1mlI Mo nda y
s0,3,7,14,
28.
• Inf
orm PublicHe a
lt
h.
• Captureani
ma l& obse
rvex10da y
s,thenexa
minebra
inf
ornegr
ibodi
es.
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|&✓⌃ ⇥✓

Te
tanusPr
ophy
lax
is:
Bas
edupo
nTe
tanusi
mmuni
zat
ions
tat
us-


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✓⌃⌦
◆⌃ ✓⌅
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✓ ✓⇥⇤⇢(⌦
$ ✓⌦" ◆ ✓⇥⇤⌦⇤⇧⌧⇧⌃6 ⌦$⌃6⌦⇢
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⌫⇧⌅ ✓⌦
⌅✓◆⇤ ⇧⇡✓⇥ ⌦ ⇤◆⇥⌦$⌦
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'(
⌦↵✓⌥⌅
⇧⇧⇡)

Se
izur
es

1. AcuteMa nag eme nt:

• I nj Di az epam 5- 10mgI Vq2-3mi nst
illse
izurest
o ps
. 23⇣↵K$ ↵⌦ ✏4⇣
• I nj Phe ny toin20 mg /kgIVa t50 mgpermi n. 2;⌦
2/>0-⌦ ⇥⇤✓⌅◆⇤⇧⇥⇢
• I nj Phe no ba rbi
tal20mg /
kgI Vat50-75 mg/min 3;⌦3⌅⇢⌥⇤⇢ ⌫
⇣;⌦
⇣⇥◆⌅⇡✓⌃⌦⇡⌥⌫⇢
• I fa llfailsthe nRSI ↵;⌦↵)⇢⇤◆⇡⌫⌥⇢
2. Pr
ima r
yGe ne r
a li
z ed& Pa rtialsei
zures
: K;⌦
K✓⇧!/ "⌅⇧!⇥⇥⇡⌦ ⇧⌦⇢#⇥
$;
⌦$✓⌅◆⇤⇧⇡✓⇥ ⇤ )
• Ta bPhe ny t
o i
n:Lo ading300 mgPO q4hx3do ses, ;⌦⇢ ⇤✓⇧⌫◆ ◆◆
;
⌦⇥⇤✓⌅✓⌅ ✓⇥ ✓⌦ ! ⇤⌦⇧⌦◆ ⌃⌦
the n300 mgPO qhs .
⌦
⌦⌦
⌦◆"⇢⇧⌅⇤⇧⇥⌦ B✓⇥ ✓⌦◆⇥✓⌫ ◆C
• Ta bVa lpro a
t e:
Lo ading15 mg /
kg /
day
,incrementsb y ↵;⌦↵✓⌥⌅⇧ ◆⇤ ✓⇢ ;⌦✓⌅
⇤⇡⇧6⌦
5- 10mg /kg /dayqwe ekly,t
il
lsei
zuresarecontrol
led. ⌦
⌦⌦
⌦⌦
◆⇤◆⌧◆6 ⌦✓◆⌃◆ ✓
• Ta bCa rba ma zepine:Start100-200mgPO o d-bi
d,
inc r
e me nt sb y200mg /perq2d,ifnee
de dti
llma x
800 mg -1200mgpe rda y.
3. AbsenceSe i
z ur
e s:
• Ta bEt ho sux i
mide500 mgPO da i
lyi
ndi v
ideddo ses
,inc
reme
ntsb y250mg / dayq4- 7dprn
til
lma x1500mgpe rda y.

Me
ning
iti
s

• Inv
est
igat
ions: CTt he
nLP ,CSFa nal
ysi
s,bl
oodC&S, neurol
ogyconsul
t
• Empiri
caladultanti
bio
tic
s:3g
rd
ener
ati
onc e
phal
ospo
rins+v a
ncomycin+ampi
ci
ll
in
I
njCe f
tr
iaxone2 gIVq12h
I
njDe x
ame thasone10mgq6hI Vx4daysforpneumococca
lme ni
ngit
is
Meningoco
c ca
l:giveco
ntact
sTa bRif
ampin600mgPO q12hx4do ses
 ⌦
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⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

CSFFi
ndi
ngs:

Cl
ust
erhe
ada
che

• TabTri
ptana ndTabPr
ednis
oneatthebeg
inni
ngofthecy
cleandprophyl
act
ictr
eat
mentwit
h
l
it
hium(300-600mgdai
lyini
ti
al
lythenmonit
orse
rum l
eve
ls)
• Dihydr
oergo
t ami
nenas
alspr
ay4mgpe r1ml.Onespra
yeachnost
ri
la ndr
epeatq15
mins.

Mi
gra
ine

1. Mil
d–Mo derate→ NSAI DS
• Ta bIbuprofe
n 200mgtid
• Ta bAspiri
n600mgPO q4h
2. Moder
ate–Se v
ere→ TRI PTANS
• Ta bSuma t
ripta
n25mgPO & repea
tq2hr
spr
n
• Ta bMe toc
lopramide10mgPO s
tat
3. Pr
ophyl
axi
s:
• Ta bPropra
no l
ol60mgPO dai
ly
• Ta bAmi t
ripty
li
ne10-25mgPO qhs.

Te
nsi
onhe
ada
che

• Ta
bTy
leno
l500
mgPO 4-
6hr
spr
n.
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|&✓⌃ ⇥✓ %

My
ast
heni
aGr
avi
s

1. Antic
ho l
inest
erase(Cho l
ine
rgic)
• Ta bMe sti
non( Neosti
gmineandPy ri
do st
igmine)
:60-120mgq3- 4h.
2. Immuno suppres
sivetherapy
• Ta bPr ednis
o ne:St
artat20mgqd, increasegra
duall
yby5mge ver
y3da y
sto60mg .
Co nti
nuef or3mo nthsoruntilcl
inicalimprovementstopsordec
li
nes
.Tapergradua
ll
yto
everyotherda y
• Ta bAz a t
hiopri
ne(Imur a
n)2mg /kg/da y
.Effec
ti
vewhe ng i
venwit
hPrednis
one.Eff
ectno
t
seenfor6mo nthsormo r
e .
Mo ni
torCBCa ndLFTs.
3. Pla
sma pheres
is(Plas
maEx change)andI VIg :Indica
tedforemergentwor
seni
ng/cr
is
is.
Responserate:
70%.

Pa
rki
nson
’sdi
sea
se

• TabCarbidopa /
Le v
odopa25/100mgPO bi d-qid,i
ncr
e a
seasneededtoma x200/2000mg/da
y.
• TabBromo cri
ptine1.25mgPO bi d.
• TabPer
g oli
de0. 05mgPO o d,ti
trat
eq2- 3da y
stothede s
ir
ede f
fect
.Ma i
ntenanc
edo sei
s3-6mg/
day
i
ndivi
deddo s
e s
.
• TabPr
emi pexo l
e0.125mgPO t i
d, i
ncre a
seto1.5-4.5mg /dayindivi
deddo s
es.
• TabRopinirol
e0. 25mgPO t i
d,increa
sewe eklytomaxdo s
e24g /day.
• TabAma ntadine100mgPO o dtoma x100mgPO qi d.
• TabSel
egili
ne5mgPO bi d.
• TabBenztropine0.5-6mg/dayPO i ndivideddoses
.
• TabEntacapone200mgg i
venc oncurr
e ntl
ywithCa r
bidopa/Lev
o dopa
.

9(
⌦⇤⇧
◆⌅)⇥⇡⇧
⇧⇡)⌦

Ac
uteSi
nus
it
is

• Ta
bAmo xici
ll
in500mgt
idPO x10da
ys.
• Deco
ngest
ant:Ta
bSudaf
ed60
mgPO q6 h
• Nas
alsa
li
ne.

Ac
utePha
ryng
iti
s

• GroupAßHe molyt
icSt
rep:
TabPeni
ci
ll
inV300
mgPO t
idx10da
ys
• Pe
nici
ll
ina
ll
erg
ic:
TabErythr
omyci
n500mgti
dx10da
ys
>⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

=(
⌦2⌥
⌫⇧⇥⇧
⇧⇡)

As
thma

1. Int
ermit
tentAs thma:Sho rtacti
ngbe ta-agoni
s t-Sa l
butamol(Ventol
in)Inha
ler1-2puffsq4-
6hprn.
2. MildIntermitte
ntAs t
hma :
• Lo ngacti
ngbetaa g
onist-Sa lmetero
lI nhaler1-2puff
sbid.
• I nhaledst
eroi
ds:
i. Fluti
caso ne(Flovent)2-4puf fsbid.
ii
. Bude s
o nide(Pulmi c
o rt
)2puf f
sbid.
ii
i.Be cl
ome thasone(Va nceri
l)1- 4puffs(40µg
)bido r1-2puff
s(80µg)bid.
3. Mo der
atePe rs
ist
entAsthma :
• I nhaledst
eroi
ds:
i. Fluti
caso ne(Flovent)2-4puf fsbid.
ii
. Bude s
o nide(Pulmi c
o rt
)2puf f
sbid.
ii
i.Be cl
ome thasone(Va nceri
l)1- 4puffs(40µg
)bido r1-2puff
s(80µg)bid.
• Lo ngacti
ngbetaa g
onist–Sa lmeterolInhaler1-2puff
sbid.
• Le u kot
rie
neRe ce pt
orAnt agonist:
• Ta bMo ntel
ukast10mgPO qhs .
• Ta bZileuton600mgPO q i
d.
4. Sever
ePer s
iste
ntAs t
hma :
• Hi g hdoseInhaleds t
eroids
.
• Lo ngacti
ngbetaa g
onist.
• Le u kot
rie
neRe ce pt
orAnt agonist.
• Sy stemicSter
oids :
i. Ta bPredni s
one2mg /k
g/dayPO ( max60mg /day).
ii
.I njMe thy l
prednis
o l
o ne(Depo -me drol
)2mg /
kgIV, t
hen0.5mg /kgq6hx5da y
s.

Ac
utee
xac
erba
tionofCOPD

• Admi twithna s
a lO2.Keeps at
urat
ionbetween88-92%.Ifs
il
entche
st/
GCS<8o rdecr
eas
edLOC
t
heni ntubat
e.
• Eleva
te dbed>45de g r
ees.
• IVF.
• MDI: 8puf f
so fVent o
lin(Sal
butamo l
)alt
erna
tewith8puf
fsofAtr
ovent(
Ipr
atr
opium)backt
oba
ck
eve
ry20mi ns3t imes.
• Nebulizer:2ccVe nt
o li
n+1c cAtroventin3ccNSq20mi nsx3times.
• InjHy droc
o r
tis
o ne125 mgI Vstat
,ifse
vere.
• InjCeftri
axone1- 2gI Vq24ha l
ongwi t
h
• InjPi
pe rac
il
lin-
Ta zobactam 3.
375gI Vq6h.
• InjMe thyl
prednisol
o ne2mg /kgIV,then0.5mg/kgq6hx5days.
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|&✓⌃ ⇥✓ 0

Communi
tyAc
qui
redPne
umoni
a

1. Out
pati
entmanageme nt:
• Ta bDoxycycli
ne100mgPO bi dx7-10days.
• Ta bEryt
hromy cin250–500mgbi dx7-10days
.
• Ta bAzit
hromy cin500mgPO o dx5days.
• Ta bLevof
loxacin500mgPO o dx7–10days
.
• Ta bAugme ntin500mg /125mgPO q8hx5da y
s.
2. I
npa
tie
ntma na
geme nt:
• I njCeft
riax
o ne1- 2gIVbidalo
ngwith
• I njLevofl
oxacin500mgI Vo dx7-10days
.
• I njAzit
hromy cin50mgI Vover1hourodx1-2days
.

Pul
mona
ryEmbol
is
m

1. I
nves
ti
gati
ons
• V/ Qs can, s
piralCTo rD- dime r(ifunlikel
yWe ll
s's
core<4)
• CBC, INR, PTT, BUN, c r
eatinine ,ALT, AST.
2. Manage
me nt :Initi
ation
• St artWa rf
arin( Co uma din)c onc urrentwithHe pari
n.
• Co nt raindicatedinpr egna ncy. (
Ifc ontrai
ndicat
edma yputIVCf i
lte
r)
• St artTa bWa rfari
na t5mgPO da i
lyonDa y1-2andHe par
in5000IUIVbo l
usfo
llo
wedby
c
ont inuo usinfusion20U/ kg/ho ur,titr
atetoINR2- 3thenstophepar
inwit
hin24hours
.
• Che c kI NRi n3- 5da ys.
• The r apeuticI NR: 2.0t o3.0I U.
• Ox yg en, andi fpaing ivemo rphineo rNSAI D.
3. Manage
me nt :Dur ationofAnt icoag ulation
• Ve ryl owr is
k :6-12we eks
• Sy mpt oma ticisolatedc alfve i
nthrombo s
is.
• Lo wr is
kpa tient:3- 6mo nths
• Re ve rs
iblethrombo embo li
smr isk(tr
ansi
entri
sksuchaspost
-ope
rat
ivePE).
• Uppe re x
tremi tyDe epVe i
nThr ombo si
s.
• Mo de rateris
kpa t
ient:6- 12mo nt hs
• Fi r
sti dio
pa thicDVTo rPE.
• Hi ghr i
skpa tient:12mo nthso rlifet
imeAnt i
coagul
ati
on
• Re cur re
ntDVTo rPEo rThr ombophil
ia.
8⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

-(
⌦⇠ ✓⌥⌫◆⇤
⇧⇧⇡)

Os
teopor
osi
s

• Ta
bCa lcium (1500mg /day
)andTa bVita
minD ( 800IU/da
y )i
nta
kei
ndietorass
uppl
eme
nts
.
• Bi
sphosphona t
es:Alendronat
e,Rise
dronat
eorRa lox
ife
ne.
• HormoneRe pla
ceme ntTherapy
• Cal
cit
onin
• Reco
mbi nantPa r
athyroidHormo ne
• Li
fes
tyl
emo difi
cati
ons:We i
ghtbeari
ngexerc
ise
s,smokingandalc
oho
lce
ssat
ion.

Os
teoa
rthr
it
is

• Ta
bTy lenol500mgPO t i
d.
• Ta
bI buprofen200- 600mgPO t id.
• Ta
bNa proxe
n125- 500mgPO bi d.
• Ta
bCe l
ecoxib200mgPO o d.
• Othertreat
me nt:
• Ta bAc eta
mi o phe
n+Ta bCo dei
ne.
• I ntr
a-art
icularcort
ic
oste
roi
dinjec
ti
on.
• I ntr
a-art
icularhyal
uroninj
ect
ion.
• To picalNSAI Ds.
• Ca psaici
nc ream.
• Gl ucosamines ulf
ate
.

Rhe
uma
toi
dAr
thr
it
is

1. Fi
rs
tChoi ce:
• Ta bNa proxe
n500mgPO bi d.
• Ta bI buprofen300- 800mgPO qi d.
• Ta bI ndome thacin25-50mgPO bi dorti
d.
2. Analge
sic
s:Ta bAc e
tami nophen500mgPO t idprn.
3. Cor
t i
cost
eroids:g
ivenint r
a-art
icula
r
i. Sma llJoi
nts:
• I njHy drocort
isone8- 20mg.
• I njMe thylpre
dni s
olone2-5mg.
• I njBeta methas
o ne0.8–1.0mg .
ii
. La rg
eJ oi
nts:
• I njHy drocort
isone40100mg .
• I njMe thylpre
dni s
olone10–25mg .
• I njBeta methas
o ne2-4mg .
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|&✓⌃ ⇥✓ '

4. Disea
seModi fy
ingAnt irheuma ti
cDr ug s(DMARDs ):Star
twi thin3mo nthsofdiagnos
ist
or educ
e
dis
eas
eprogre ss
ion.
i. Mi lddi s
ea s
e:
• Ta bHy droxychloroquine200mgPO bi d.
• Ta bSul fas
alazine500m mgPO bi dt otid.
ii
. Mo deratedisease :
• Ta bMe thotrexate10- 15mgPO o ncewe ekly,thenincr
easet
o20mgPO o nce
week l
y.
• Co mbi natio
nt herapy:
• Me tho t
rexate+Sul f
a s
alazine+Hy drox y
chlor
oquine.
• Me tho t
rexate+Cy closporine.
• Me tho t
rexate+Et anercept(biologicalDMARD) .
ii
i.Biolo gi
calDMARDs : usedinpe rsi
stentdisease:
• Et aner ceptSC.
• I nf
lixi
ma bIV.
• Ana kinraSC.
• Ada li
muma bSC.
• Aba ta
c eptIV.
• Ri tuxima bIV.
NOTE:
• I fCort
ico
ster o
idsa r
eus edf or>3mo nths,doba se
li
neDEXAa nds t
artbi
sphosphonatet
herapy.
• S/ EofCo r
tic os
teroi
ds :Os teopo ro
sis,cat
a r
act
s, gl
auc oma,pept i
cul c
erdis
ease,
avas
c ul
arnecr
o s
is
,
hyper
tens
ion, i
ncreasedi nfect
io nrate,hypo ka
lemia, hypergly
ce mia,hyper
li
pidemia
.
• C/ ItoCo r
ticoster
o i
ds:Ac ti
veinf e
c t
ion,hypertensi
o n,diabet
e sme ll
it
us,gas
tri
culc
e r,
ost
eoporosi
s.

Gout

1. Ac
uteGout:
i. NSAI Ds: TabI ndo me thaci
n25 - 50mgPO t idx10- 14da ys.
ii
. Ta bNa prox e
n500mgPO bi dx4- 10da ys
.
ii
i.Ta bCo lchici
ne0. 6mgPO q1ht illpainreli
ef(ma x4- 6do s
es)
,thenbidx3-5days.
iv
. Sy s
temicSt ero i
ds:(ruleo utSe pt i
cAr thri
tis
)
• I nj Me thy l
predni s
o l
one40mgI Vs ingledose
• I nj De ro-Me dro l80-120mgI Ms ingledo s
e.
• Or al:TabPr e dnisone40mgPO o dx5da y s
,theng radual
lyta
perthedose
.
v. I nt
ra-
Ar ticularCo rti
c ost
ero i
d: use di nlarg
es i
ng l
ejoints& ref
ract
orycase
s.
• I nj Be t
ame tha s
one7mgo rI nj ACTH 40- 80IU.
2. Re
curr
entGout :Tr eatfor3- 6mo nths.
i. Ov erproduc ers:Ta bAl lo
pur ino l100- 300mg /dayPO.
ii
. Unde r-excreters
:Ta bPr obe necid250mgPO bi d(ma x:1500mgbi d)orTabSulf
apyr
izi
ne50
mgPO bi d(ma x:1000mgbi d).
ii
i.Co ncurrentlystartwi thTa bCo lchi ci
ne0. 6mgPO bi dx3- 6mo nths.
9⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Te
mpor
ala
rte
rit
is

• Sta
rthi g
hdo seTabPrednis
one60mgPO o duntilsy
mptomss ubsi
deandESRno r
ma l
• The n40mgPO o dfor4-
6we eks
• The ntaperto5-10mgPO o dfor2year
s(re
laps
eso cc
urin50%i ftr
eat
me nti
ster
mi na
tedbefo
re2
yea
rs).Treat
me ntdoesnotal
terbio
psyres
ult
sifthesampleist
a k
enwi t
hin2weeks.
• Mo ni
torESRr egula
rly
.
• Ifvi
sualsymptomsa r
eprese
nt,ordevel
opduri
ngt re
atment,
thepati
entisadmit
tedandg i
ven
InjPrednis
olone1000mgI Vq12hf or5days.

Pol
ymy
alg
iaRhe
uma
tic
aMa
nag
eme
nt

1. Gener
almeasure
s
• Co nsiderconc urrentTe mpo ralAr teri
tis(Seea bove)
• NSAI Ds
2. Pr
edni
sone(keytoma na geme nt)
• Se eCo r
ticosteroidAs sociate
dOs t
e o
po rosi
s
• Ef f
icacy
: 90%r esponse
Dr ama t
icimpr oveme nti nfirst48ho urs
Ifnor esponset os ter
o ids–r econsiderdi a
g no si
s
Re cons i
de rdia gnosis
Co nside rMe tho t
rexate
• Po l
ymy algi
aa lone
Do se: 15-20mgPO qd
• Po l
ymy algi
awi thTe mpo ralAr t
e ri
tis
Do se: 40-60mgPO qd
Sy mpt omsa nds ignsr emi twithin1mo nt h
De crea s
edo s
eb y10%e achwe eka ft
erimpr ov e
me nt
• Co urse
• I niti
al: Ma intains tar
tingdo sefor1mo nth
• Fi rsts ter
oidt ape r(depe ndso nc li
nicalrespo nse)
Ta perb y2. 5mgpe rmo nthdo wnt o10mg /
daythen
Ta per1mgpe r4- 6we eksdo wnt o5t o7. 5mg/day
• Fi nals teroidt aper
Indic atedwhe ns ympt omf r
eef or6- 12mo nths
Dono ttaperunt i
lsedime ntati
o nr ateno r
ma l
iz
es
Ta perb y1mge very6- 8we eksunt ildo ne
• Ant i
c ipate2- 6y earco urseo fsteroi
ds
Re lapsec ommo ninf ir
st18mo nthso fste
roi
dus e
Pa ti
ent so f
fste r
o i
dsa t2y ear
s :25%
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|&✓⌃ ⇥✓ =

Fi
bromy
alg
ia

1. ANTI DEPRESSANTS: Be nefi

ts
• As sist
swi thl oc alpain,sti
ff
nessa
ndsle
ep
• Do esno taffe ctTe nderPo i
nts
2. Tr
icycl
icAnti
de pressant s
• Ami tr
ipty l
ine( Elavil
)
i
. Fi rs twe ek :10mgPO qhs
i
i. Ne x tthr eewe eks
:25mgPO qhs
i
ii
.La ter: 50mgPO qhs
• No r
triptyli
ne( Pa me l
or)
3. NovelAnti
depre s
sant s
• Ve nlafaxine( Ef fexor)
• Dul o x
e ti
ne( Cy mba lta
)
4. Se
lecti
veSer
o t
o ninRe uptak eInhibi
tor
s(SSRI)
• Co mbina ti
o n: Fluo xet
ineandAmi t
ri
ptyl
ine

Se
pti
cAr
thr
it
is

• Gonoc
occal
:InjCeft
ri
axo
ne1 gIVq24hx2-
4da
ys,
thenswit
chtoTabCipro
flo
xac
in500mgPO
bi
dx7da y
s.
• Non-
Go noco
ccal
:InjNaf
ici
ll
in2gIVq4hx2we
eks
,thenswi
tchtoTabCipr
ofl
oxa
cin500mgPO
bi
dx2-4weeks.

(
⌦@⌅
⇧⇧⇡)4
↵✓ ⌅
⇧⇧⇡)

Ur
ina
ryt
rac
tinf
ect
ion(
UTI
)

1. Ac
uteuncompli
cate
dUTI :out
pati
ent
• Ta bBactr
im DSPO bi dx3da y s
.
• Ta bNitr
ofuranto
in(Ma cr
obid)100mgPO bi dx5days.
2. Dr
ugresi
st
antUTI :outpati
ent
• Ta bCiprof
loxaci
n500mgbi dx3days.
• Ta bNo r
fl
oxacin400mgPO bi dx3days.
• Ta bOfloxa
cin200mgPO bi dx3da y
s.
3. Ac
utecompli
cate
dUTI :i
npati
ent
• I njAmpi ci
ll
in1-2gI Vq4- 6handInjGentamic
in2mg /
kgIVloadi
ngdos
efol
lowe
dby1.
7
mg/kgq8hI VOD
• I njCiprof
loxaci
n400mgI Vbid.
• Swi t
chtoo r
alanti
biot
icsuponimprove
me ntforato
talcour
seo
f14-21day
s.
%-⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Ac
utePy
elone
phr
it
is

1. Outpati
entmanageme nt:Foracuteunco mplic
ate
dc a
ses
• Ta bCiprof
loxaci
n500mgPO bi dx10da y
s.
• Ta bGa t
if
loxaci
n400mgPO da i
lyx10da ys
.
• Ta bMo xif
lox
a ci
n400mgPO da i
lyx10days.
• Ta bLevofl
oxacin250mgPO da ilyx10days.
• Ta bAugme ntinbidx14da ys
.
• Ta bBactr
im bidx14da ys.
2. Inpa
tie
ntma nagement:IVf or48-72ho urs,t
henswit
c htoo
ralag
ent
s.To
taldur
ati
onoft
rea
tmentf
or
14days.
• I njCef
tri
axone(Ro cephin)1-2g ramsIVq24ho ur
s.
• I njCef
otaxi
me( Claforan)1g r
a mI Vq12ho urs
.
• I njAmpici
ll
in2gI Vq6hwi t
hI njGe nt
amicin2mg/kgIVl
oadi
ngdo s
e,the
n1.
7mg /
kg
q8h.
• I njPi
perac
il
lin3.375gI Vq6h.

(
⌦⇣⌫✓⌅
⇡✓⇥ )⌦
&✓⌃ ⇥✓4
2⇧⇢
⇧⇥⇥⇡

Ac
eta
minophe
nInt
oxi
cat
ion

• Toxi
clev
eldo s
eismo r
ethan7.5g
• Inv
est
iga
tions:Mo ni
tordruglev
elsta
ta ndthenq4h(Ace
tami
nophennomo
gra
m),
LFT,
INR,
PTT,
BUN, Cre
atini
ne,ABG, Glucos
e
• Rx: Cha rc
oal/
Ga s
tri
clava
geaspe rprese
ntat
ion
N- ace
tylcys
tei
ne140mg /k
gPO, then70mg/k
gq4hfor18dos
es

Al
cohol
wit
hdr
awa
l

• Tr
eat
ment: InjDia
zepam 10-20mgIV
InjThi
amine100mgI Mthen50-100mg/
day
Flui
dresus
cit
ati
onwi t
hD5W 1-2mL/kgIV

Al
le
rgi
cRe
act
ion

1. Se
ver
e:InjEpi
nephri
ne0.3-
0.5mgSC/I
Ms t
at
2. Mil
d:TabBenadry
l25-50mgPO q6hx3d
3. Ta
bPrednis
one60mgPO o dx3d

Ana
phy
lax
is

• Epine
phrinea ut
oinje
ctor(EpiPen)ifav
ail
able
• Epine
phrineIVo rETT: 1mlo f1:
10,
000ina dult
s
• InjDi
phe nhydramine(Benadry l
)50mgIVo rIM q4-6h
• InjMethylpr
ednisone50-100mgI Vaccor
dingtos e
veri
ty
• Ifwheezi
ngo rspasm pr
e s
ent: Sal
buta
mo lvianebul
izer
.
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|&✓⌃ ⇥✓ %

Ar
rhy
thmi
as

• Arr hythmi asdueto2ndde gr

eea nd3rdde g
reeheartblo c
k:
InjAt ropine0.5mgI Vwhi l
ewa it
ingfortransc
ut a
ne ouspacing .
Trans cuta
ne ouspacingf ir
st(giv
eI njMi dazol
am2 mgf orsedat i
on)
Admi tfort r
ansveno uspa ci
ng
• Uns tablepa ti
ents(hypo te
nsivesystol
icBP<90, chestpain,SOB, al
ter
edme nta
lsta
tuso r
unc onscious):CARDI OVERT!
• Stablepa tient:
Atrialfibri
llati
on: eit
he rchemicalcardi
oversi
on( Ami odarone )orel
ectr
ica
l(Synchro
niz e
dDC
cardioversi
o n)
Vent ri
culart a
chycardia: DCc ardiovers
ionorI njLidocaine
/ Ami odaro
ne150 mgIVov er10mins.
Vent ri
cularfibri
ll
ation: Alwaysde fi
bril
lat
e!Synchronizedca rdiover
si
onno tuse
fulbecauset
her
eisno
QRSc ompl extosync hroniz
ewi th.
PSVT: Va ls
alvaorc aro
tidma ssage(aft
ercheckingfo rbrui
t),I njAdenosi
ne6 mgrapidIVpush.
Ifnor e s
po nsethenMe taprol
ol,Di l
ti
azem.

ASAI
ntox
ica
tion

• Inv
est
iga
tio
ns: Druglev
els
,el
ect
rol
yte
s,ABG,BUN,
Crea
tini
ne
• Rx: Ga s
tri
clava
ge/Charc
oal
Alkal
iniz
eurinewit
hD5W, KCla ndNa
HCO3
Aim:uri
nepH >7. 5

Di
abe
ticke
toa
cidos
is

• Est
ima t
edda i
lybasalglucosere
qui reme ntis0.5U/ kg
• Inv
e s
ti
gati
ons: Bl o o
dg l
ucose
,ele ct
rolytes,ABG, serum ke tones,osmo largap,ani
ong ap,BUN,
creat
inine.Looko fthec ause: Ur i
na l
ysi
s,bl oodC&S, chestx
-ray,ECG.
• Mo nit
or: Ur i
neo utput,
ex tra-ce
llularfl
uidv olume ,e lect
rolytes,ABG, creati
nine,
capil
larybloodg lucosea ndleve lofc onsc
io usnesseve r
y1- 2hour s
.
• Ma nage
me nt: Re hydrati
on: NS1L/ hi nf i
rst2ho ursfol
lo wedb y0. 45%NS500c c/
hthe nswit
ch
toma intainbl
o odg lucose13.9- 16.6mmo l/Lt oa v
o idrapiddecreaseofosmo l
al
it
y.
K+r eplacement: Asa c i
do si
sisc orrecte
d, hypo k
a l
e miama ydev el
op.
IfK+i s3.3-5.
0mmo l
/L, addKCl20- 30mEq/ Ltok eepitwithinthisr
ang e
.
Cor rectaci
dosis: IfpH <7. 0/hy potension/ c
o mat heng ive3ampNa HCO3
(150mEq/ L)
Re ducebloodg lucose: Sta r
tIns ul
int herapywi th0. 15U/ kgbolusandma int
ain
0.1U/ kg/hunti
la cidosisandbl o odg l
ucoser esol
v e
.
Treatunde rl
yi
ngpr eci
pi t
ant.
%⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Di
gox
inI
ntox
ica
tion

• Inv
est
iga
tio
ns: Plasmadigoxin/di
git
oxinle
vels
,ECG, elect
rol
yte
s,BUN, Cr(l
eve
ls>2.
6indi
cat
e
intox
ica
tion)
• Rx: Tr eatarrhyt
hmias(commo nwi thdigo
xinintox
icat
ion;v
fib
,vt
ach,c
onduc
tio
nbloc
ks)
Ga s
triclav
age/Cha rcoal(
1g/kg)fori
ngesti
on
Na HCO3o rglucoseandinsuli
n
Ventricul
artac
hycardia:Digi
bind10-20vial
sifdoseunknown
Chro nicto
xici
ty:thenDi gi
bind3-6vial
sIVov er30mins.
Foll
owECG, K+,Mg +
,Dig
oxinleve
lsever
y6ho urs.

Hy
per
tens
ivee
mer
genc
y

• Systol
icBP^180 mmHga ndDi as
tol
icBP^120 mmHg( withsig
nsofacut
eorg
andamag
e)
• Invest
igat
ions: CBC, elect
rol
yte
s,BUN, Cr
e at
inine,ABG, Ur i
nal
ysi
s,CXR,ECG,BPinallfo
ur
li
mbs ,Fundosc
opy,Ca r
diol
ogyc onsult
.
• 1stLine:Inj Sodium nitr
oprus
side0.3mc g
/k g/minIVORI njLabe
talo
l20mgIVbol
usq10mi ns.
• Ao r
ticdis
sectio
n: Sodium nitr
opruss
ide+bb l
ock e
r(esmolol)
• Ca t
echola
mi nee xce
ss: I
njPhentola
mi ne5-15mgI Vq5- 15mi ns
• MI /Pulmonarye dema: InjNit
rogly
cerin5-20mc g/minIV,increa
seby5mcg/mi
neve
ry5mi nti
ll
symptomsi mprove.

Hy
pog
lyc
emi
a

• Inv
est
iga
tio
ns: Ba seli
nebloo dg l
ucose,
insul
inandC- pept
ide
,che
ckgluc
oseq15mins
unti
l>5mmo l/
L
• Rx: I fpat
ientcaneat/dri
nk: g
ive15gca r
bohydra
teifBG <4mmo l
/L(15ggl
uco
setabso
r_c
aps
ofjui
ceor3s poonso fsugarinwa t
er.
)
NPO : giv
e25gc arbohy dra
teifBG <4mmo l/
L(D50 W 50ccIVpush1ampOR
D10W 500c cIVORg lucagon1-2mgI M/ SC)

Me
tha
nol
/Et
hyl
eneg
lyc
oli
ntox
ica
tion

• Inv
est
iga
tio
ns: CBC,el
ect
roly
tes
,gl
uco
se,
met
hano
lle
vel
.
• Rx: Et hano
l10mg
/kgover30minsORInj
Fomepi
zol
e15mg
/kgI
Vov
er30mi
ns.
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|&✓⌃ ⇥✓ %%

Opi
oidI
ntox
ica
tion
• Me nta
lstat
use ffectsi ncludeeupho r
ia,sedati
on,decre
asedanxie
ty,
asenseo ft
ranqui
li
tya
nd
indi
ffe
rencet opa i
npr oduc e
db ymi l
d- t
o -moderat
eintoxi
cati
on.Seve
reint
o xi
cati
oncanl
eadt
o
deli
ri
um andc oma .
• Physiol
ogic
a leff
e ctsinc l
udet hefoll
owi ng:
Respi r
ator yde press
ion( mayo ccurwhilethepati
entma i
nta
insconsci
ousnes
s)
Alterati
o nsi nte mperatureregulat
ions
Hy povo l
e mi a(trueaswe llasrelat
ive)
,le
adingtohypotens
ion
Mi osis
Softt i
ssuei nfection
Increases phinc tert
one( canleadt ouri
naryret
entio
n)
• Treat
me nt
IVg lucose: 50%De x t
rose50ml
InjNa laxo ne0. 4mgupt o2mgI Vforrever
salofopioi
dintox
ica
tion.
InjThi ami ne100mgI Ms t
at& OD x3da ys
O2, intuba ti
o n& me chanicalventi
ll
ati
on

Shoc
k(Ca
rdi
oge
nic
/Ne
urog
eni
c)

• Do
pami
ne: 1-
3mc g/
kg/mi
nist
her
ena
ldo
se;
4-10mc
g/k
g/mi
nist
hei
not
ropi
cdo
se
• Do
but
amine:2.5-
5mc g
/kg
/min

Spr
ain(
Ankl
e)RI
CE

• Rest
• Ic
e: usi
ngba gofice,applyduringtheda yfor5-20mi
nse
ver
y2ho
urs
.
• Compr ess
ion:Tenso rbandageo rspec
ialsuppor
ts.
• Elev
a t
ion: El
evat
et heank l
ea smuc haspo s
sibl
e.
• Analges
icsasneeded.
• Crutchesifto
opa i
nfultobe arwe i
ght.

St
roke

• Inv
est
iga
tions: CBC, electro
lytes,
BUN, glucos
e,creati
nine,INR/ PTT,lipi
ds,ECG, c
aro
tiddoppl
er
i
fsuspe cti
ngTI A,ABG, No ncontrasturgentCTs c
an.
• Tre
atments: NPO, Fo l
e ycat
he t
er,DVTpr ophylaxi
s,Ne urol
ogyconsult
Ruleo utc ontra
indicati
onsf o
rthrombo l
yti
ctreat
me nt.
Uregentne urol
ogyc onsul
t.
Thr o
mbo lysi
s: rTPAwi t
hin3ho urso fsymptoms
Ant i
-coa g
ul at
ion: Lowdo seHe parin5000Ubi d,st
artWa rfa
rinwit
hin3days
,
mo nit
o rINR/ PTT
Ifunablet othrombo l
yseoranti-
coa g
ulatethen: TabASA50- 325mgodo r
TabCl o pi
do grel75mgo d
BPc ont rol:decreasesl
owly,IVLa betalol(Fi
rstl
inetrea
tme nt)
Bedr est,analgesi
cs,mildsedati
ona ndl a
x a
tiv
es,avoi
dhy per
g l
ycemi
a.
%>⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

TCAI
ntox
ica
tion

• Pat
ient
swhopr es
entt otheED f o
llowingpsychot
ropicdr
ugov e
rdos
ewithGCSZ8s houl
dunde
rgo
i
ntubat
ionattheearli
estopport
unitytopreventhypovent
il
ati
onandaspi
rat
ionpneumonia
.
• Inv
esti
gati
ons:Dr uglevel
s,ECG, ABG, el
ectro
lyt
es,LFTs,RFTs.
• Rx: Ac ti
vat
edc harc
oal1gm/ kgviaNG
Diaz
epamf orseiz
ures
WideQRS/ Sei
zures:NaHCO3(1- 2mEq/ kgbol
usdo s
eandthen100-150mEqi n
1LD5/0.45%Na Clinfused100-200ml /
hI V)

Uppe
rGIBl
eed

• Sta
bili
zepati
entwit
hI VF,cros
s& t y
pe,2lar
gebo r
eI Vcannula
s.
• Inv
e s
ti
gati
ons:CBC, plat
elet
s,I
NR, BUN, crea
tini
ne ,
PTT, el
ect
rol
ytes
,LFTs
• Ma nage
me nt: NG t ube,NPO, bloodt
ransf
usi
o nifnee
ded,upperGIe ndosc
o py
InjOc tr
eoti
de50 mcgloa
dingand50mc gpe rhour(f
orvari
ces)SC/I
V
InjPantoprazo
le50mgI Vstatand50mgq8h( gas
tri
culcer
)

Lowe
rGIBl
eed

• Sta
bili
zepati
entwi
thIVF,cros
s& type
,2lar
geboreIVcannulas
.
• Inv
e s
ti
gati
ons: CBC, pl
atel
et
s,I
NR/ PTT,BUN, cr
eat
inine,
elec
tro
lyt
es.
• Ma nage
me nt: NG tube,NPO,bloodtr
ansf
usi
onifneeded,s
igmoido
scopy
,co
lono
sco
py,
ang
iog
ram
(f
ora
ng i
odys
plas
ia)

Wa
rfa
rinI
ntox
ica
tion

• Tre
atmentac
cordi
ngt oINRl ev
els
INR<5: Stopwarfari
n,obs
ervat
ion,se
rialINR/ PTT
INR5-9:Ifnor i
skf a
cto
rsforble
eding,holdwa rf
ari
nx1- 2days& r
educemaint
enancedos
e.
ORVi taminK1- 2mgPO, ifpa t
ientati
ncrea
sedris
korFFPf ora
ctiv
eblee
ding.
INR9-20:Stopwa rf
ari
n,Vita
minK2- 4mgPO, se
ria
lINR/ PTTthenaddit
ionalVi
taminKif
neededo rFFPforacti
vebleeding.
INR>20: FFP10- 15ml/kg
,InjVi t
aminK10mgI Vov er10min,i
ncre
asedoseofVit
aminK (q4h)
i
fneeded.
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|&✓⌃ ⇥✓ %0

%(
⌦⇧⌥⇥⇢
✓⇥⇡

Smoki
ngc
ess
ati
on

1. Nicoti
negums :2mgi f<25c ig/
day,4mgi f>25c i
g/day
• 1pi eceq1- 2hf or1-3mths
2. Nicoti
nepatch:
• 21 mgpe rda yf or4we eks
• 14 mgpe rda yf or2we eks
• 7 mgpe rda yf or2we eks
3. Nicoti
neinhaler
: 6-16c art
ri
dg e
spe rdayupt o12we e
k s
4. Bupropio
n(Zy ban):
• 150 mgqAM x3da ys,t
hen150mgbi dfor7-12we eks
• Ma i
ntena nce150mgbi dforupt o6mo nt
hs.
• Ge ne ra
l
Stops mokingdurings econdwe eko fmedi
cat
ion
StopBupr opionifuna bletoquitby7we ek
s
Mi nimum o f8ho ursbetweendo ses
Mo reisno tbett
er
Swa ll
owpi l
lswho l
e( notcrushed,divi
dedorche
wed)
.

Al
cohol
ces
sat
ion

Pr
oto
col
:Al
coho
lDe
pende
nce ⌘⇣⌦
P⌥✓⇢
⇤⇧⇥⇥◆⌅
✓

• La
bma
rke
rs ⌦
;⌦
3◆ ✓⌦ )⇧⌥⌦✓ ✓⌅⌦✓⇤
⌦⇤✓⌦⇥✓✓⌃⌦
Se
rum Gammag l
uta
mylt
rans
fer
aseo
r ⌦
⌦⌦
⌦
⌦⌦
⇤⇧⌦@$⌦ ⌃⇧!⇥⌦⇧⇥⌦)⇧⌥⌅⌦
⌦
⌦⌦
⌦
⌦⌦
⌃⌅⇥#⇥⇡Q
Car
bohydr
atede
fi
cie
ntTr
ansf
err
in ⌦
;⌦
3◆ ✓⌦ )⇧⌥⌦✓ ✓⌅⌦✓⇤
⌦
⌦
⌦⌦
⌦
⌦⌦↵↵ K⇣*⌦ ◆⇤⌦⌅⇤ ⇢ ⌫⌦⇧⌦
1.
Ini
t i
alMana g
eme nt ⌦
⌦⌦
⌦
⌦⌦
)⇧⌥⌅⌦⌃⌅⇥#⇥⇡Q
• Ta bThi amine100mgPO qd ⌘⌦;
⌦3◆ ✓⌦)⇧⌥⌦✓ ✓⌅⌦✓⇤
⌦⌘@.$K⌦
⌦
⌦⌦
⌦
⌦⌦
◆"⇧⌥⇤ ⌦)⇧⌥⌦
⌃⌅⇥#⇥⇡Q
• Ta bFo l
ate1mgPO qd
⇣⌦
;⌦
3◆ ✓⌦)⇧⌥⌦ ✓ ✓⌅⌦◆⌃⌦◆⌦
⌃⌅⇥#⌦
• Mul tivi
taminqd ⌦
⌦⌦
⌦
⌦⌦⌅⇢⇤
⌦⇤ ⇥⇡⌦ ⇥⌦⇤✓⌦ ⌫⇧⌅⇥⇥⇡⌦
• Tr ea
tHy pomagnese
miaifpr
ese
nt ⌦
⌦⌦
⌦
⌦⌦
B⇣K⇣⌦2⇣↵⇣⇠C Q
• Se i
zurepr e
caut
ions
2.
Lo ng-Te
rm Abs ti
nenc
ePr ogr
ams
• Al cohol
icsAno nymous
• Spo nsor
• Tr ea
tme ntProgra
m
• Ha lfwayHo use
%8⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
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⌦
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⌦
⌦⌦
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⌦
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⌦⌦
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⌦
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⌦⌦
⌦
⌦⌦
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⌦
⌦⌦
⌦⌦
⌦
⌦⌦
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⌦
⌦⌦
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⌦⌦
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⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

3.
Adj
unc
ti
v eMe di
cati
onsf ora bst
inenc e
1.Firs
tli
ne(conside rNa l
trexonewi thCa mpr al)
• Ta bNaltrex one
Block sOpi oidre c
e ptors
Decre ase spleasuref rom Al coho l
Dosing : 50mgo rallyda i
ly
Eff
e ctivei nsho rt-term, butno tinlong-t
erm
• Ta bCampr a l(Ac ampr os at
e)
Balanc esGABAa ndg l
ut amat eneurotra
nsmitt
ers
Reduc esa nxiet
yf ro ma bstinenc e
Do sing :2t absPO t id
2.Secondli
neage ntst oc onsider
• Se lect
iveSe rotoninRe upt akeInhi bitor
s(SSRI )
Co ns i
dere speciall
yi fcomo rbi
dde pre
ssi
on
Pr oz acoftenus ed,buto the rSSRIse f
fec
ti
ve
• Topi rama te( To pama x)
De creasesAl co holus eseve ri
tyandbingedrinki
ng
Impr oveswe l
lbe ing,qua l
it yofli
feinAlcoholi
cs
3.Ag e
ntstoavoi
d
• Ant a
buse
Ta k en250t o500mgo r
allyda i
ly
No tr ec
o mme nde dduet or is
kandunc ert
ainbenef
it

• De
li
ri
umTr
eme
ns

Ge ne
ralProt
ocol(Requir
esICUobser
vati
on)
• TabDi az
epam( Vali
um)
Do s
e:10-25mgPO q1hpr nwhilea
wake
Endpoint:unti
lade
quat
eseda
tio
n
• InjLoraze
pam( Ativan)
Do s
e:1-2mgI Vq1hprnwhileawakef
or3-5da
ys
Endpoint:unti
lade
quat
eseda
tio
n
• Libri
um (Chlor
diazepoxi
de)
Do s
e:50to100mgPO/ IM/I
Vq4h( max:
300mg /
day
)
Endpoint:unti
lade
quat
eseda
tio
n
↵⌥⇤
%9⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

"⇢
⇤✓⇤
⌅⇢⌦
:⌦⌘)⇥✓ ⇧
⇧⇡)⌦
1.
Sex
ual
lyTr
ans
mit
tedI
nfe
cti
on
a
.Chl
amydia
:
TabAz i
thro
my ci
n1gPO st
atorTa bDox
ycy
cli
ne100mgPO bi
dx7da
ys
Ifpr
egnant:TabEry
thromy
cin 500mgPO t
idx7days.
Trea
tpartner
,Repor
tabl
edi
sea
se.

b
.Gonor
rhea:
InjCeftr
iax
one125mgIMs t
at+TabDo
xycy
cli
ne100mgbi
dx7da
ys.
Ifpr
e gna
nt:Inj
Specti
nomyc
in2gIMst
at
Treatpar
tner
,Repor
tabl
edi
sea
se.

c
.Sy
phi
li
s:
Pri
ma r
y,Seconda ry,LatentSy phil
is(durat
ionle
ss1year):
InjBenzathinePe nicil
li
nG 2. 4MUI Mf or1dose
Treatpartner,Repo r
tabledis
e a
se.
Ifal
lerg
ict oPe ni
cill
in:TabDo x
ycycl
ine100mgPO bidfor14days.
Lat
elatent,Cardiov a
scular(durati
onov er1year)
InjBenzathinePe nicil
li
nG 2. 4MUI Mo nceaweekfo
r3we eks
IfPenic
ill
ina ll
ergic:Ta bTetrac
ycli
ne500mgPO qi df
or4we e
kso r
TabDo x ycycl
ine100mgPO bi dfor4we eks
Neuros
yphi l
is:Inj Aque o
usPe nici
lli
nG 3- 4MUI Me v
ery4hour
sfor10-14da
ys.

d.
Geni
tal
herpes:
Fir
stepis
ode: Ta bAcyclovir400mgPO ti
dx10da ysor
TabFamc i
clovir250mgti
dx10da ysor
TabVala
c yc
lovir1gbidx10days
Recurr
ent: TabAcyclovir400mgPO ti
dx5da ysor
TabFamc i
clovir120mgbidx5daysor
TabVala
c yc
lovir500mgbidx5days
Suppres
si
on:ifmoret
han6e pisodespe
ryea
r
TabAcyclovir400mgPO bidx12mo nt
hs
Sever
eepiso
de:I njAcy
clovir5-10mg /
kgq8hx5-7days

e
.Ge
nit
alwarts(HPV) :
Loca
lt r
eat
me ntwi
thLI
QUI D NITROGEN repe
ateve
ry1-2we eks
Podophyl
lot
oxin0.
5%gelbi
dx3days,
the
n4daysof
f–tobere pe
atedfo
r4
week
s .
Pr
ophy l
axi
sforHPV(fo
rCe r
vic
alCA& war
ts)–InjGarda
silIM 0,2and6mo
nths
.
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦| "⇢
⇤✓⇤
⌅⇢⌦
:⌦⌘)⇥✓⇧
⇧⇡) %=

GENERALI NSTRUCTI ONSf oral

lsexual
lyt
rans
mitte
dinf
ect
ions
:
• Trea
ta l
lpartner
s
• Avoidsexualint
erc
ourset
il
ltr
eatmentcomple
tio
n.
• Barr
iercontrace
pti
on/educa
teaboutsaf
esexpra
cti
ces
.
• Rescr
eeningin3mo nt
hs.

SIDEEFFECTS:
• DOXYCYCLI NE:Drugi
nduc
edPHOTOSENSI TIVITY,us
esunscr
een
• ACYCLOVI R:he
ada
che,
GIupse
t,i
mpa
ire
dre
nalfunc
ti
on,
tre
mo r
s,a
git
ati
on,
let
har
gy,
co
nfus
ion,
coma

2.
Uri
nar
yTr
actI
nfe
cti
on

Unc
ompl
ic
ate
d:
TabBact
rim DSPO bi dx3da y
so r
TabNitr
ofura
ntoin100mgPO qi dx5days
.(wi
thf
ood)
Inpre
gna nc
y:Tre
ata s
ympt omat
icUTI
TabAmo xi
cil
li
n250mgPO t idor
TabMa c
robid100 mgPO bidx10da y
s.
Pyel
onephri
tis
:AcuteUnc ompli
cat
ed:
TabCipr
ofloxa
cin500mgPO bi dx10daysor
TabAugme nti
n625mgPO bi dx14da ys
.

I
npa
tie
nt:
Inj
Ceft
ri
axo
ne1gIVbi
dfor48hour
sthenswi
tc
htoo
raldr
ugs+
InjGe
ntami
ci
n50mgIVq8hfor24hour
s.

3.
Vul
vov
agi
nit
is
a.
Candidi
a sis:
Ta bMi conazole200mgPVqhsx3da ysor
Ta bNy stat
in(100,00unit)vagi
naltabPVqhsx14da ysor
Ta bFl uc o
naz o
le150mgPO s ta
tdo s
e.
Prophy laxis:4ormo reinfec
ti
onpe ryear–TabFluco
nazol
e150mgPO e
ver
y
3da ysfo r3do ses
.
Ma intenance:TabFl uc
o nazol
e150mgPO e achweek.Monit
orl
iv
ere
nzymese
ver
y1-
2
mo nths.
b.Ba
cter
ialv agi
nos i
s:
Ta bFl agyl500 mgPO bi dx7da ys
.(wit
hfood)
c.
Tri
chomona sv agi
na l
is:
Ta bFl agyl2gPO f or1do se.or
Ta bFl agyl500 mgPO bi dx7da ys
.(wit
hfood)
,tr
eatpar
tner
.
d.At
rophicv aginiti
s:
To picalEs t
rogenc re
am 0.5to2gda il
ytobeappl
iedloc
all
y.
>-⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
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⌦
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⌦⌦
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⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
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⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

4.
Pel
vi
cInf
lamma
tor
yDi
sea
se(
PID)

a
.Outpat
ient
:InjCe ft
ri
axone250mgI Ms ta
tdose+Ta bDoxycyc
li
ne100mgPO bidx14day
s.
b
.Inpa
tie
nt:I
nj Cefoxi
tin2gIVq6h+I nj Doxyc
ycl
ine100mgI Vq12h.
ContinueIVf or48hrs& thentabDo xy
cycl
ine100mgPO bidx14days
.
Reportabl
ediseas
e,t
reatpa
rtner
s,r
escr
eeni
nga f
ter4-
6we e
ksinc
aseo
fdocument
ed
infec
tion.

5.
Dys
func
tiona
lUt
eri
neBl
eedi
ng(
DUB)

a
.Mil
dDUB:
• NSAI Ds–Ta bMe f
enamicac
id500 mgPO t idx5da y
s,
• Ani t
fibri
nolyti
cs–Tranex
amicacid500mgPO t i
dx5da y
s,Co
mbi ne
dOCPS
• Mi rena/Pr over
a
• Ta bPr oge
stinonetabOD infi
rst10-14days.
b
.Se
vereDUB:
• I njPr emari
n25mgI Vq4h+Ta bGr avol50mgPO q4h.
• Wi thTa bOv ralPO ti
dti
llbl
eedi
ngs t
o ps(24hrs
),
THEN bidfor2days
,THEN o
dfo
r
3days.
• Co ntinueconventi
onalOCPsifpregnancyno tdes
ir
ed.

6.
Dys
menor
rhe
a

• TabIbupr
ofen400mgPO qi dfro
m 1stdayofmens
trua
lcyc
le.
• OralContr
acept
ivePil
ls
.
• Import
anttorul
eo uts
econdar
ycaus
eso fdy
smenor
rhea.

7.
Endome
tri
osi
s

a) NSAI Ds: TabIbuprof

e n400mgPO qi dti
lls
ymptomsl
ast.
b) OralCo ntr
acepti
vepil
ls.
c) TabProv e
ra10-20mgPO OD.
d) TabDa nazol600-800mgPO OD f or6months.
e) GnRH Ag oni
st:InjLeuprol
ide3.
75mgI Mo nceamonthfor6months
.
InjGoser
eli
n3.6mgSCe ver
y28daysfor6months.
UseGnRH Ag o
nistal
ongwi thEs
tro
g e
n/Pr
o g
est
ero
neaddbackthe
rapy
.(Tor
educ
ethes
ide
ef
fec
tsofbo neloss.
)
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦| "⇢
⇤✓⇤
⌅⇢⌦
:⌦⌘)⇥✓⇧
⇧⇡) >

8.
Hor
moneRe
pla
ceme
ntThe
rapy(
HRT)

a) OnlyEs t
roge
n-Ta bPr ema r
in0.625mgPO OD (o nl
yestroge
n)
b) Cycl
icDo se–TabPr e
ma ri
n0. 625mgPO OD a ndTabPr ov
era5- 10
mgPO OD f rom da
ys1-
14.
c) Sta
ndarddo s
e-Ta bPrempr o(premari
n0.625mgandprovera2.
5mg )c ombi
nat
ionpi
llPO OD.
d) Pul
sati
le–Ta bPremarin0.625mgPO OD a ndLowdo seTabPr overa1.
5mgPO OD.
Give
na s3day so
na nd3da yso f
f.
e) Tr
ansdermal:Estr
adioltr
ansdermalpatc
ht wi
cedai
lya
ndTa bPr overa2.5mgPO OD.

9.
Eme
rge
ncyc
ont
rac
ept
ion

• OTCnopres
cript
ionnee
ded.Tak
ewi t
hin72ho ur
so funpr
ote
ctedint
erc
ours
e.
• Ta
bOvral2ta
bsPO q12hx2do ses(
ha sLevonor
gestr
el0.
5mg/dose+est
rog
en0.
1mg
/do
se)+
Ta
bBena
dryl10mg1hrbe for
edose(emesi
sinducedbyEstr
ogen).
• Pl
anB(TabLe vo
norge
str
el0.
75mg /
tab)onetabq12hrsx2doses.

10.
GroupBSt
rept
ococ
cus(
GBS)i
npr
egna
ncy

• InjPeni
cil
li
nG 5MUI Vt hen2.
5MUI Vq4hti
lldel
iv
ery
.
• Penic
ill
inal
ler
gic
:InjCefa
zoli
n2gIVt hen1gq8ho r
InjCl
indamyci
n900mgI Vq8ho r
InjEr
ythromyc
in500mgI Vq6h.

11.
Pre
gna
ncyI
nduc
edHy
per
tens
ion(
PIH)

a.
Initi
al
:Toma int ainDBP<100
• I njLa be talo l20mgI Vbo l
use very10- 20mi nsprn.(C/ Ias
thma,CHF)
• Ta bNi fe dipineXL10mgPO v ery20- 30mi nsprn.
• I njHy dra l
a zine5mgo r10mgI Me v e
ry20mi nspr n,then5o r10mge v
ery3hrspr
n.
(
S/E: fetalt achy car
di a,maternalhe adache
,pa l
pit
ations)
b.Mainte
na nce:
• Ta bMe thy ldo pa250- 500mgPO bi d–qid.
• Ta bMe to pro lol25- 100mgPO bi d.
• Ta bLa be talo l100- 400 mgPO qi d.
c.
Ant i
convulsantt he ra py:
• I njMa g ne si
um s ul
fa t
e4gI Vbo l
usov er20mi n,followedb ymainte
nanceof2-
4g /
ho ur
.
• Mo nitors ignso fMa gnesi
um to xici
ty–de press
edde ept e
ndonr e
fl
exes
,decr
eas
edrespir
ato
ry
r
e f
lex,anur ic, hypoto nic,
CNSo rc ar
diacdepress
ion.
• Ant a
go nistt oMa g
ne s
ium sulf
ate: Calci
um g l
uconate(10%)10mlI Vov e
r2minutes
.
d.Avoi
dthe seant ihy pe rt
ensiv es
:
• ACE( -)& ARBs–ne onatalre
na lfail
ure,t
eratogenic,IUGR.
• At enolo l–I UGR
• Thi azidedi ure ti
cs–ma ternalf
luidde plet
ion.
>⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

12.
Ect
opi
cPr
egna
ncy

a)I njMethotr
exa
te50mg/m2BSAIMs t
atdos
e.
b) Repea
tbe t
ahCG leve
lswee
klyt
il
l<1.
c) Contr
acepti
onti
llbe
tahcgre
tur
nsto5
mI U/
mlorl
ess
.
d) DoCBC, LFTs.

13.
Hype
reme
sisGr
avi
dar
um

Ta
bDi c
lec
ti
n(10mgDo x
yla
mi newi
th10mgPy
rido
xin)s
tar
teda
s1t
abqAM +1t
abqPM +
2t
absqhs.
Ma x
imum 8t
absperday
.

14.
Drug
scont
rai
ndi
cat
edi
npr
egna
ncy

• Chl oramphe nicol :Gr ayba b ysyndr ome

• Eryt hromy ci
n: Ma terna lliverda ma ge( usedo nlyi fa l
lergi
ct ope nicill
in).
• Fluor oqui nolone s: Ca rtil
ag eda ma ge.
• Me troni da z
ol e
: Ant i- me tabo l
ite,highr iski n1stt rime st
era ndbr eastfe eding. Ca nl e
adt omi scar
ria
g e
.
• Sulfadr ug s:Mi sca rriagei n1 t
st
ri
me s
tera ndk e r
nicte r
usin3 tr
d
rime ster.
• Tetra cycli
ne s:St aini ngo ft eethi nc hil
dre n.
• ACEi nhibitors: IUGR, oli
g ohydr amino s,feta lrena ldefec
ts.
• Ant iconv ulsants:
▪ i )Phe ny toin:Fe talhy danto i
ns yndr ome–I UGR, facialdy smo rpho ge nesis
,cardiovasc
ular
de fe ct
s, cong enitalano ma lieso fha nd& f o ot,umbi li
c alhe r
ni aa ndc ongenital
a no ma lies.
▪ i i)Va l
pr oica c i
d:Lumbo sacr
alspi nabi fidawi t
hme ning omy elo cel
eo rme ningocele,of
ten
a cco mpa ni edb ymi dfacialhy popl asi
a ,
deficiento rbit
a lridge, promine ntforehead,
c ong enitalhe artdi sease,andde c r
e asedpo stnatalg r
owt h.
▪ i ii
)Ca rba ma z epine :Uni quef aci
a la ppe arancea ndunde rdev e
lo pme nto fthefingers,t
oes,and
na ils;de velopme ntaldelay .
▪ i v)Phe noba rbital:Cl eftpa l
ate/l
ip ,co ngeni talheartdisease ,i
nt ra-cr
a nialhemo r
rha g
e.
• DES: Va gina lade no sis,ade nocarcino ma ,uter i
nema lf
o r
ma tionsinf ema l
ef etuse s
.
• Lithium:Ebs tein’
sc a rdiaca no ma ly,goi
ter, hy pona tremia.
• Mi sopr ostol:Co ng e nitalfac i
alpa ralysi
swi t ho rwi tho utli
mbde fects(Mo biuss yndro me)a ndNe ural
tubede fects.
• Retinoi ds:De fo r
mi tieso fthec ranium, ears,f ac
e, l
imbs ,andl i
ver,hydr ocepha lus,mic r
o c
epha l
y,
he artde f
e cts,co gni t
ivede fects
, cranio faci
a lalter
ation,cleftpa late,neur altubede f
e ct
s,
cardiova scula rma l
forma t
ionsa ndk idne ya ltera
tions.
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦| "⇢
⇤✓⇤
⌅⇢⌦
:⌦⌘)⇥✓⇧
⇧⇡) >%

• Warfa
rin:Highrisko fspo ntaneousabo r
ti
on, s
till
births
,IUGR.
Fet
alWa r
farinSy ndrome:De for
mi t
ieso ftheaxia
landappe ndi
cul
a rs
k e
leton,hypopla
sti
c
nose,opti
ca trophy ,mentalreta
rdati
o n,brachydac
tyl
y,sc
oli
o si
s,menta
lretardati
on,int
ra-
cra
nialhemo rrhag e.
• Al
cohol:Highincidenceo fa borti
ona ndstil
lbirths,IUGR.
FetalAlcoho lSy ndrome :De cr
easedmus cletoneandc oo
rdinati
on,cognit
iveimpa i
rment,
ASD/ VSD, narro ws malleyeswithlargee pic
anthalf
olds
,sma l
lhead,s
ma llmid-face,
i
ndist
inctphi l
trum, t
hinuppe rli
p.
• Cig
aret
tesmoking :IUGR, place
ntalabrupti
o/pr evia,s
pontane
ousabo rt
ion.
• Cocai
ne:IUGR, mi cr
o cepha ly,
prematurit
y,me ntalretar
dati
on.
↵⌥⇤
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|2✓⌃◆⇤
⌅⇢ >0

2✓⌃◆⇤
⌅⇢
1.
Acut
eBr
onc
hiol
it
is

a
. Mi l
ddistr
ess:
oral
/IVhy dra
tion,
ant
ipy
ret
icsf
o rfe
ver
,humidi
fi
edO2,VENTOLI N 0.
03cci
n3mlNS
byfacema s
kq20mi nandthenq1hr.
b
. Mode rat
etosever
edi s
tres
s:al
lthea
bove+Ri bavi
ri
ninhig
hr i
skgro
upsli
kecongenit
all
ungdi
sea
se,
congenit
alhea
rtdis
ea s
e,br
onchopul
monarydy s
pla
sia
,immunodef
ic
ientpa
tie
nts
.
c
. Antibio
tic
s,i
prat
ropium,syst
emicco
rti
cos
tero
idshavenouse.

2.
Acut
eOt
it
isMe
dia(
AOM)

a) Fi
rstl
ine
:
Ta bAmo xi
ci
ll
in80-90
mg /kg/
dayPO divi
dedq8hfor10d.
Ifall
erg
ic–TabAz i
thro
my ci
n10mg /k
g/dayOD for3days
.Tobeg
ive
nifc
hil
d>6mo
nths
old.
b) Se
condli
ne :
TabAug menti
n90mg /
kg/daydiv
idedq12hfor10daysor
TabCe fur
oxi
me30 mg/kg/
daydivi
dedbidfor10days
.
Av oi
dFLUOROQUI NOLONESunde r16year
sage.

3.
Ast
hma

• Cl
ass
if
ication(NI Hr ecomme nda ti
ons)
a)I ntermittentAs thma -Oc cas
ionalexace
rbati
ons(Lessthantwiceperweek).
b) Mi ldPe rsi
stentAs t
hma -Fr equentexac
erbati
ons(>twic
ewe ekl
y,butnotdai
ly)
.
c) Mo derat
ePe r
sistentAs thma -Da i
lysymptomswithda i
lyBetaAg onis
tuse
d) Se v er
ePe r
si
ste ntAs thma -Co nti
nuousSy mptomsandf re
quentexacer
bat
ions.
• Ac
uteMa na geme nt
i. O2( toma i
ntainO2s a t
urati
on>90%) .
ii
. Fl uids,ifdehy dra t
ed.
ii
i.β2Ag onist:Sa lbutamo l(Ventoli
n)-0.03c c
/kgin3c cNSe ver
y20mi nute
sfor3do s
esthen
0.15-0.3mg /kg( nott oexceed10mg )e v
e r
y1-4ho ursasneededor0.5mg/kg/ho
urb y
cont i
nuo usne bulizat
ion.
iv
.I fSe ver
e–I pra t
ropium bromi de(Atrove
nt)1ccaddedtoe ac
ho ffi
rst3sal
buta
mo lmasks.
v. St e r
oids:InjPr ednisone2mg /kginER, then1mg/kgPO OD x4d.

4.
Ba c
ter
ialTra
cheiti
s
• Ai rwayma nagement,kee
pchil
dc al
m.
• Humi dif
iedO2
• Ne bul
ize
dr ace
mice pi
nephr
ine(
1:1000s
olut
ion)in3
mlNS, 1-
3dose
s,q1-
2h.
• I njCeftr
iaxone75-100mg/k
g /
dayq24hr
s+I njVa
ncomy
cin40mg/
kg/dayi
ndi
vide
ddo
sese
ver
y
6-8h.
>8⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

5.
Bac
ter
ial
Pne
umoni
a

Ne
wbor
n(under3weeksold)
1. Admital
lnewbornswithPne umo nia.
2. Ant
ibiot
icr
egimen(Us e2-3antibio
ticsc omb i
ne d)
a) Anti
b i
oti
c1:Ampi cill
in
i. Ag e<7da ys
• We ight<2k g: 50-100mg /kgdividedq12h.
• We ight>2k g: 75-150mg /kgdividedq8h.
ii. Age>7da ys
• We ight<1.2k g :50-100mg /
kgdi videdq12h
• We ight1.2-2k g :75-150mg /kgdi videdq8h.
• We ight>2k g: 100 -
200mg /kgdivide dq6h.
b) Anti
b i
oti
c2:Ge ntamicin(dosingbe l
owi f>37we ek so l
d)
• Ag e<7da ys:2.5mg /kgrepeatedq12h.
• Ag e>7da ys:2.5mg /kgrepeatedq8h.
c) Anti
b i
oti
c3:Ce fot
axime( opti
o nal)
• Ag e<7da ys:100mg /
k gdivi
dedq12 h.
• Ag e>7da ys:150mg /
k gdivi
dedq8 h.
3. Organi
smsrequi
ri
nga ddit
ionalanti
bioticc overage
i. Me thicil
li
nRe sis
tantSt aphy l
oco c
cusAur eus( MRSA) -Va
ncomycin
a) Ag e<7da y
s:
• We ight<1. 2k g: 15mg /k gIVOD.
• We ight1. 2–2k g: 10-15mg /kgIVq12-18h.
• We ight>2k g10-15mg /kgI Vq8-12h.
b) Ag e>7da y
s, we ight>2k g:45-60mg /
kg/dayi
ndivi
dedIVq8h.
ii. Chlamydiatrachoma ti
s- Erythromy ci
n30- 50mg /
kg/dPO divi
dedq8h.

Ma
nage
me nt:Age3we ekst o3mont hs
1. Outpatie
nt(ifafebri
lewitho utres
pira
torydis
tr
ess)
i. Az i
thromy ci
n10mg /kgday1,5mg /kgda y
s2-5PO.
ii
. Er ythromy ci
n30- 40mg /
k g/
dayPO dividedq6hx 10da
ys.
2. Inpa
tient(i
ffebri
leo rhypox ic
)
i. I njErythromy c
in40mg /
k g/
dayIVdividedq6ha nd
ii
. Oneo fthef ol
lowinga ntibi
oti
csiff
ebri
le:
• I njCefotaxime200mg /kg
/dayI Vdivi
dedq8h.
• I njCefurox i
me150mg /kg/
dayI Vdivi
dedq8h.
3. Crit
ic
a l
lyil
l
i. I njCe f
otaximea sab oveandInjCloxaci
lli
no r
ii
.I njCe f
uro x
imea lonea sabove
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|2✓⌃◆⇤
⌅⇢ >'

Ma
nage
me nt:Age3mont hst o5y ears
1. Outpatie
nt( i
fa f
ebril
ewi thoutr espirato r
ydi str
e s
s)
a) Co nsideriniti
alpa r
ente r
ala nt i
bioticatdi agnosi
s:
• I njCe ftri
ax o
ne50mg /
k g/dayupt o1g r
a mI Mx 1dos
e.
• St a
rto r
ala nti
bio t
icsc oncurrentlyasbelow.
b) Fi rst
-lineo r
ala gents:
• Amo xici
lli
n90mg /kg /
da yPO di v
idedq8hx 7-10d.
c) Al ternati
v eoralag e
nts:
• Amo xici
lli
n-Cl avula nicAc id( Aug mentin).
• Er ythromy ci
n.
• Cl ari
thromy cin.
• Az it
hr o
my c i
n.
2. Inpa
tient(i
ffebr i
leorhy po x
ic):
a)I njCe fotaxi
me150mg /kg/da yIVdi vide dq6h.
b) I njCe furoxime150mg /
kg/ da yI Vdi v
ide dq8h.
c)I fconf i
rme dPne umo co ccalPne umo nia:
• I njAmpi cil
lina l
one200mg /
k g/dayIVdi videdqh.
3. Crit
ic
a l
lyil
l:
a) Opt i
o n1
• I njCe fotaxime150mg /kg/dayI Vdividedq6ha nd
• I njEr ythromy cin40mg /kg/dayI Vdivide dq6h.
b) Opt i
o n2
• I njCe furoxime150mg /kg/dayI Vdivide dq8ha nd
• I njCl oxacill
in150- 200mg /kg/dayIVdi videdq6h.

Ma
nage
me nt
:Ag e5to18years
1. Outpat
ient
:
a) Firs
t-l
ineorala gents
:
i
. Er y
thr omy c
in40mg /
kg/dayPO div
idedq6hx7- 10d.
i
i. Clarithromy ci
n15mg /
kg/dayPO divi
dedq12hx7- 10d.
i
ii
.Az i
thr o
my c
in
• Da y1: 10mg /
kgda y1PO (ma x
imum 500mg ).
• Da ys2- 5:
5mg /kg/da
yPO (ma xi
mum 250mg )
.
b) Pneumo cocc
a lPne umoniaconfi
rmed:
i
. Amo xici
lli
n90mg /kg/
dayPO divi
dedq8hx7- 10d.
2. I
npati
ent:
a) Firs
tli
nea ndi nc ri
ti
calil
lnes
s:
i
. I njCe furoxime150mg /
kg/dayIVdivi
dedq8ha nd
i
i.I njEr ythromycin40mg /kg/dayI
Vdi vi
dedq6h.
b) Pneumo cocc
a lPne umoniaconfi
rmed:
i
. I njAmpi cil
li
n200mg /k
g/dayIVdivi
dedq8h.
>9⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

6.
Croup(
Lar
yng
otr
ache
obr
onc
hit
is
)

a) Humidif
ie
dO2
b) Nebul
iz
edracemi
cepinephr
ine
(1:
1000so
lut
ion)in3mlNS,1-
3dose
s,q1-
2h:
• Chi l
d<6mt hs:0.
25ml
• Chi l
d>6mt hs:0.
5ml
• Ado le
sce
nt:0.
75ml
c) Dexamet
haso
ne0.6mg /
kgIM/IV/PO,maxdose10mg,
giv
enasas
ingl
edose.

7.
Epi
glot
ti
ti
s

• Suspectepi
glo
tti
ti
sifchildha sf
eve
r,i
lll
ooki
ng,dys
pnea
,dy
spho
nia
,lo
sso
fvo
ice
,st
ri
dor
,sudde
nin
ons
e t
.
• Inv
e s
ti
g a
tio
ns: Pha ryng ea
lswabandcult
ure
Bloodc ult
ure
Late
ralX- raynec
k(Thumbpr i
ntsi
gn)
ABG, CBC
Endosco pyinER
• Tre
a t
me nt: Int
ubation
IVfl
uid
IVCe furoxi
me

8.
Str
ept
ococ
cal
Pha
ryng
iti
s(Gr
oupASt
rept
ococ
cus
)

McIsa
acCri
ter
ia–noc oug h,t
enderanter
iorcervic
ally mphno des,e
rythe
mat
ousto
nsi
lswit
hex
uda
te,
f
eve
r>38°C,age3-14years.
a)If1symptomo nly–noc ul
tureora nt
ibi
o t
icsne eded.
b) I
f>1s ymptom, cult
ureposi
ti
ve–t reatwit
ha nti
bioti
cs:
Penici
lli
nV40mg /kg/
da yPO dividedbi dx10da ys.
Erythromy ci
n40mg /kg/dayPO div i
de dtidx10da ys
.
Ac e
taminophe nforfev
ero rpain.
c)Invas
iveGAS: ne edsadmiss
ion–
InjClindamy ci
n40mg /
k gdivi
dedi nto3- 4dosesand
InjPenicil
li
n250000–400000U/ kg/daydivi
dedinto6do
sesx10days
.

9.
Whoopi
ngCoug
h(Pe
rtus
sis
)

a) Eryt
hromyci
n40-50mg/kg/
dayPO divi
dedqidx10d.
b) Azit
hro
my ci
n10mg /
kg/PO OD day
1,5mg /
kgPO OD da
y2t
oda
y5.
(pr
efe
rre
d)
c)I s
ola
tefor5day
so ft
rea
tment.
d) Eryt
hromyci
ntoallt
hehousehol
dme mber
s.
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|2✓⌃◆⇤
⌅⇢ >=

10.
Bac
ter
ial
Meni
ngi
ti
s(Re
por
tabl
edi
sea
se)

a)I njDe xame tha sone0. 6mg /kg/

dayI Vi n4di vi
deddo ses
.Startwit
hin1houro
f1sta
nti
bio
tic
dose..
b) Ampi ci
ll
in:
i. Ag e<1mo nth–50mg /
kgI Vq8- 12h.
ii
. Ag e>1mo nth–50mg /kgIVq6h.
c) Ce f
o tax
ime :
i. Ag e<1mo nth–50mg /kgIVq8- 12h.
ii
. Ag e>1mo nth–200mg /kg/
dayI Vdi v i
dedq6-8h.
d) Ce f
tr i
axone:
i. Ag e<1mo nth–50- 75mg /kgI Vdi videdq12-24h.
ii
. Ag e>1mo nth–100mg /
kg/dI Vdi videdq12h.
e) Ge ntamy ci
n: 2- 2.
5mg /kgIVq8h.
f) Vanc omy ci
n: 15mg /k
gq6hI Vx7- 14da y
s .
g) Prophy l
axisfo rc ontact
s:
i. H. Infl
u enz ae: Rif
ampin20mg /k g/dayupto4da y
s.
ii
. N. Me ning itides:
• Rifampi n
• Chi l
dren:10mg /kgPO q12hx2da y
s(ma x600mg)
.
• Adul t
s:600mgPO q12hx2da ys.
• Ci proflox aci
n(adult
s)500mgPO f oronedo se
.
• Ce ftriaxo ne:
• Ag e<15years
: 125mgI Mforo nedose.
• Ag e>15y ear
s: 250mgI Mf oronedo s
e.

11.
Febr
il
eSe
izur
es

a)InER: I
njDiazepa
m 0.2–0. 5mg/k
gIVq15
minst
il
lse
izur
est
ops
.
b) Ho
me: Dia
zepamre c
talsuppos
it
ory
.
c)Inv
est
iga
te& tr
eatthecauseoffe
ver
.

12.
Uri
nar
yTr
actI
nfe
cti
on(
UTI
)

1. Ora
l Tre
atme nt-for7-14da ys.
i. Ce fi
xime( Suprax
)8mg /kgPO divi
dedbi dor
ii. Ce fpodoxime( Vanti
n)10mg /kgPO dividedbidor
iii.Ce fprozi
l(Ce f
zil
)30mg /
kgPO di v
idedbidor
iv. Ce pha l
exi
n( Kefl
ex)50-100mg /
k gPO divide
dqid.
2. I
Va nti
biot
ic s
i. I njCe fotaxi
me50- 150mg /
kg/daydivi
dedq4-6ho r
ii.I njCe ftr
iaxone50- 75mg/kg/
daydividedq12-24h.
3. UTIPr ophy l
axis
i. Ba ctr
im( 2mgTMP/ 10mgSMZpe rk g
)a tbedt
imeqhs
.
0-⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦⌦
⌦⌦
⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

13.
All
erg
icr
eac
tion

a) GeneralMe as
ures:
i. ABCma nagement.
ii
. Ox y ge
n.
ii
i.I VF.
iv
. Ne bulis
edbe t
a-a
gonis
t(Albuter
o l
).
b) Anaphylaxi
swithairwaycompromise
: Epinephr
ine(1:
1000so
lut
ion)0.
01ml/
kgSC/
IM(upto0.
3ml
)
c) Urt
icar
ia,Pruri
tusorFlus
hing:I
nj Diphenhydra
mi ne25-
50mgIM/ IVeve
ry6hr
spr
n.Ora
ll
ysame
dos
eq6hx3da ys.
d) Pr
eventio
n:
i. Me dic
alal
ertbra
cele
t.
ii
. St r
ictavoi
danceofal
ler
g e
n.
ii
i.Epi Pen.
iv
. Al l
e r
gytest
inganddesensi
ti
zati
ont her
apy.

14.
Ane
miai
nchi
ldr
en

• 6
mg/kg/dayel
ementa
lir
o nbi
d-t
id.
• I
nve
sti
gatetheca
useofanemi
a.

15.
Dos
eof
Tyl
enol
inc
hil
dre
n

a) 40-
60mg /
kg/
dayPO di
vi
dedq6hrpr
n(nott
oex
cee
d5do
ses
/24ho
urs
).
b) Neona
tes
:10-
15mg/kgPO q6-
8hrprn.

16.
Immuni
zat
ionSc
hedul
eforI
nfa
ntsa
ndChi
ldr
eni
nCa
nada
↵⌥⇤
0 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

2⇢
) ◆⇤
⌅)

(
⌦⇡⇤
◆⇤⇧⇥⌦
:⌦⇡⇡⌅
✓⇢⇢⇧⇥⌦
Agit
ati
oncanbedefi
nedase
x c
essi
veve
rbaland/o
rmo to
rbehavi
or.I
tca
nreadi
lyes
cal
atet
oag
gre
ssi
on,
whi
ch
ca
nbee i
the
rverba
l(vi
ci
ouscurs
ingandthre
ats)orphy
sic
al(
towardobj
ect
sorpeo
ple)
.

Goa
lsoft
rea
tme
nt(
Nonpha
rma
col
ogi
cal
tre
atme
nt)

• Createas afeenvi
ronme ntfortr
eatment
• Dec r
ea s
estimulati
on
• Per
mi tpa t
ienttove nti
latehisorherfee
li
ngs,butt
hismayne e
dtobecutsho
rtift
hedegr
eeof
agi
tationise s
cal
ati
nga ndt her
eiscle
ardangertos
e l
fandother
s.
• Behav io
ralapproachesinc l
udenevertur
ningyourbacktoanagit
ate
dpati
ent
,ta
lki
ngso
ftl
yra
thert
han
shouting,andinquiringa boutwhatspeci
fi
cneedsthepati
entmayhave
• Preventfurtherepi
s odeso fagi
tat
ionoraggre
ssi
on

De
li
ri
um

• Deliri
um o rac ut
ec onfusi
ona lst
ateisac ommo na nds eve
reneuropsychiatr
icsyndr
omewi t
hc o
re
fe
atureso facuteo nsetandfluct
uatingco urse
,atte
nti
o naldefi
ci
tsandg ene r
ali
zedsev
ere
di
sorg a
nizationo fbeha v
ior.
Tr e
atme ntofde l
iri
um require
streat
me ntoft heunderl
yi
ngc a
uses
.
• Antipsychoticsaref i
rst
-li
netreat
me nt.Ha loperi
dolisthemo steff
ec t
iveme di
cati
onfordecr
easi
ng
agi
tationinde lir
iouspa t
ient
s .
Firstgenerati
ona nti
psychoti
cLox apinea ndsecondgener
ati
on
(a
typical)antipsychotic
ssucha sOl anzapine,Ri
speri
donea ndQue ti
apinec anals
obeused.
Benz odiazepiness houl
dber eserv
e dforc a
sesofalcoholwithdra
wa l.

Fi
rs
t-g
ene
rat
ionAntips
ychot
ic
s(FGA)
• Ha l
oper
idol:0.
5-2.
5mgPO/IM bi
d ↵$2✏K 3 $ ✏⌦ ✏4⇣
⌘ A✏⌘
⇣⌧⇤⌅
◆ )⌅◆⌫ ⌃◆⌦
✏4⇣⌦,⌦ ⌥⇤ ✓⌦
• Lox a
pine: 12.5- 50mg /dayPO ⌃)⇢⇤⇧⇥◆6⌦
2◆⌅#⇥⇢⇧⇥⇢ ⌫6⌦
Se
c o
ndg enerat
io n(at
ypic al)a
ntipsyc
hoti
cs(SGA) ◆#◆⇤◆⇢◆6 ⌦
$◆⌅
⌃ ✓⌦ ⌃)⇢#⇥✓⇢◆(
↵✓⌥⌅⇧✓ ⇤⌦&◆⇡⇥◆⇥⇤ ⌦
• Ol anza pine:5- 10mg /dayPO, 2.5-10mgI
M(r
epe
at2ha
nd6hpr
n ✏)⇥⌃⌅⇧⌫✓⌦B↵&✏C
toma xo f30mg /24h) ✏✓⌃◆⇤⇧⇥
• Ri speridone: 0.5-2mg /dayPO ?✓⇡ ⇤ ⌦⇡◆⇥6⌦
⌃◆"✓⇤ ✓⇢⌦◆⇥⌃⌦
⌃)⇢ ⌃✓⌫ ◆
• Que ti
apine: 25- 100mg /dayPO 3) ✓⌅⌅ ⇧◆⇤⇥✓⌫ ◆⌦ ◆⇥⌃⌦
Benzodi
azepines ⇢✓⌧⌥◆
⌦⌃)⇢⌥⇥ ⇤⇧⇥(
• Lor azepa m: 0.5- 1mgPO/ IM q6-8h
• Ox azepam: 10- 15mgPO t id
$ ✓⌅
◆ ✓⌥⇤ ⌦
⌘⌥⌃✓⇥✓⇢
⌦|2⇢
) ◆⇤
⌅) ⌦
⌦ ⌦
0%

Ma
nia

• Ma niaisastateo fabnormall
yeleva
tedorirr
it
ablemo od,
arous
al,
and/o rener
gylevel
s.Tre
atmentof
maniainvolvesbo thacutecont
rolofseve
reagit
ationb yamo odst
abil
izerandlongter
m mo od
s
tabil
izers.
Initi
allyatypic
alanti
psyc
ho t
ic
ssucha sRisperi
done,Olanz
apineorQue ti
apineareef
fec
ti
ve.
Fi
rs
t-g
enera
t i
onAnt ipsychotic
s
• Ha loperidol:5-10mg /dayPO/ I
M
At
ypic
alant
ipsychoti
c s
• Ri speri
done: 2-3mg /dayPO
• Ol anz a
pine: 5-20mg /dayPO,2.5-10mgI M( repeat2hand6hpr ntoma xof30mg /
24h)
• Que ti
apine: s
tartwi t
h100mg /
dayPO; i
ncr
easeb y100mg /dayasneededto300-600mg /day
divi
de dBI D

(
⌦⇥⌧✓⇤
)⌦*⇢
⇧⌅⌃✓⌅
⇢

• Anxi
etydi
sor
dersa
reag
roupofco
ndit
ionswit
hexa
gge
rat
eda
nxi
ous
nes
sandwo
rrya
boutanumbe
rof
co
ncer
nspers
is
tsfo
ranext
ende
dperi
odo ft
ime.

Goa
lsoft
rea
tme
nt(
Nonpha
rma
col
ogi
ctr
eat
ment
)

• St
ressr
educt
ionandr e
lax
ati
ontec
hniquess
uchasmedi
tat
iona
ndl
owi
mpa
cty
ogai
sof
tenhe
lpf
ul.
• Cognit
ivebe
havio
ralther
apy(CBT)
• Reduct
ionofcons
umpt i
onofcaf
fei
nea ndot
hers
ti
mula
nts.
• Minimizeus
eo fa
lcohol

Pa
nicdi
sor
der

• Pani ca tt
ackorpa nicdi sorderinv olvess uddenanx i
etyt ha to ccurswitho utwa rning.Sympt omsc an
includec he s
tpa in,he artpalpit
a ti
ons ,swe ati
ng,shortne s
so fbr e
ath,feelingo funr eal
it
y,trembli
ng,
dizziness,naus ea,ho tflashesorc hil
ls,af eeli
ngo flosingc o ntrol,oraf earo fdying .
Panica t
tacksar
e
extreme lyc ommo n-10%t o20%o ft hepo pulat
ione x perienc eapa nica tt
ac katso mepo intinthei
r
l
ife.So mepe o pl
es tarttoa voi
ds ituationst hatmightt rigge rapa nica ttack;thisiscall
edpa nicatt
ack
witha g oraphobia .Pani cdisor
de rreferst orecurr
ingf ee l
ingso fter
rora ndf ear,whi c
hc omeo n
unpr edictablywi thouta nyc le
art rigger.
• SSRI sa ndSNRI sa ret hefirs
tc hoicei nthet re
atme nto fpa nicdisorde r
s.Se l
ectiveserot
o ni
nr e
uptake
inhibitors(SSRI s)likeCi tal
opr am, Es cit
a l
opram, Fluox etine ,Paroxet i
nea ndSe rt
rali
nea real
l
eff
e cti
v einre ducingpa nicatt
ack s.Se r
o toninnorepine phriner e
uptak einhibi t
or( SNRI s)eg.
Venl afaxineisa l
sous edi npanicdi sorde r
.
• The rei sade layint heo nse
to frespo nset othesedrug swhi chma ybea ccompa niedb yiniti
alagi
tat
ion.
Co mbi ningSSRIo rSNRIwi thabr i
e fcourseoflowdo s ebe nz o
diaze pinec aninc r
easeadhe r
enceto
me dicationa ndpr oduc erapidre s
po nse .
• Ot herme dicatio
ni nc ludeTr i
cyc l
ica ntidepress
ants(TCAs )e g.I
mi pra mine ,De s
ipraminea nd
Clomi prami nea ndMo no a
mi neo xida seinhibi
tors(MAOI s )eg.Phe ne l
zine,Tr anyl
cypromi ne.
0> ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Se
lec t
iveseroto
ni nr eupt akei nhibito r
s( SSRIs
)
• Pa roxetine: 20- 60mg /
da yPO ✏⇣⇠ $ ↵ ↵⌦ ✏K↵*⇠ &⇣⌦
⇧⇥⌥⇢⇧⇥6 ⌦
⌃⇢ ⇧⌅✓⇥⇤ ◆⇤⇧⇥6⌦
• Fl uoxetine: 20- 80mg /da yPO ◆⇡⇤ ◆⇤⇧⇥6 ⌦✓ ✓⌅ 6⌦
⌃◆ ⇧⌅ ✓⇢⇢6⌦
• Se rtr
aline: 50- 200mg /da yPO ⇢⇥⌥⇢ ⌦⇤
◆ )◆⌅ ⌃◆6 ⌦
3$↵6 ⌦
⌫)⌃⌅◆⇢⇢ 6
⌦⇤◆ ) ⇥✓◆6 ⌦
• Ci tal
opr am: 20- 60mg / da yPO ⌫)⇧  ⇧⇥ ⌦ M✓⌅#⇢ 6
⌦) ✓⌅ /
• Es cit
alopr am: 10- 20mg /dayPO ⌅✓ ✓⌧◆6⌦
⌫⌥⇢ ✓⌦⌅⇡⌃⇤ )6
⌦
⇤⌅
✓⌫⇧⌅ 6
⌦◆⇤◆⌧◆6 ⌦ ⇥ ⇧⇧⌅⌃⇥◆⇤⇧⇥(⌦
Se
ro toninnorepine phr iner euptak einhibitor(
SNRIs
) $⇠⇣ $&⇣↵$; ⌦
+✓⇥5 ⇧⌃◆5 ✓ ⇥✓⇢⌦
⇢
⇤
• Ve nlafaxine: 37. 5-22.5mg /day B⌦ ⇥✓C6
⌦✏✓⌅ ⇧⇤⇧⇥⇥⌦
⇥⇤ ◆⇡⇧⇥⇢ ⇤
⇢ ⌦
;⌦) ⌅ ⇧ ✓⇤ ◆⌃⇥✓6⌦
Tr
icy c
licanti
depr essant s( TCAs ) &✓⇤)⇢ ✓⌅⇡⌃✓6 ⌦2⌅⇧⌅ ◆⇥⇧⇧
(
• Cl omi prami ne: 75- 225mg /day
• De s
iprami ne: 75- 300mg /day
• I miprami ne: 75- 300mg /day
Benz o
di a
zepines
• Al prazolam: 0. 25mgt i
d- qid, upto1mgPO qi
d
• Cl onaz epam: 0.25- 0.
5mgPO bi d
Mo noa mineo x
ida sei nhi bitors(MAOI s)
• Phe ne l
zine: 45- 90mg /da y
• Tr anylcypr omi ne: 20-60mg /day

Soc
ial
Phobi
a

• So cialanxiety
,al
sok nowna ssoci
alpho bi
a,i
nvolvesexcess
iveanxiet
yinsocia
lsit
ua t
ionswhe r
epeo pl
e
fearbe i
ngemba rra
ssedo rma defuno f.Si
tuat
ionsthatcant r
iggersoci
alanxi
etyi
nc l
udesma llgro
up
discuss i
ons,dati
ng,goingt oapa rt
y,andplayi
ngs ports
.Co mmo ns ymptomsofsocialanxi
etyincl
ude
blushi ng,s
we at
ing,anddr ymo ut
h.Pe o
plewithso c
ialphobiaoft
e navoi
ds oc
ials
ituati
onsthatcause
anx ie
t y.
• SSRIa ndSNRIa rema instaydrugsforthetr
eatme ntforsoci
alphobia.Esci
tal
opram, Fl
uv oxamine,
Pa roxe t
ine,Sert
ral
inea ndVe nl
afa
xinema ybeus edformi l
dercases.
• Simpl es ta
gef r
ightorfea rofpubli
cs peaki
ngma yre s
pondt olowdo sePropr
anolol10mgt aken30
mi nut esbef
o r
ethee vent.

Ge
ner
alAnx
iet
yDi
sor
der

• Gener al
izedanxie
tydi sorder(GAD)i sass
o ci
atedwithc onti
nualexces
si
v ea nxiet
ya ndwo rryabouta
numbe rofthings(e.g
.,wo r
k ,
mo ney,chi
ldren,andhe a
lth).Therei
snos pe cif
icsourceo ffe
ar.
Sympt omsc anincl
udemus cl
etensi
o n,t
remb l
ing,shortnessofbre
ath,fa
s the ar
tbeat,di
z z
iness
,dry
mouth, nausea,
sle
epingpr obl
ems ,
andpo o
rc oncentr
ation.CBTi sthemo ste f
fect
ivepsychosoci
al
tr
eatme ntbutoftentake s20o rmo resess
ionstobee ff
e ct
ive.
• SSRIsa ndSNRI shav ebe comee s
tablis
heda sfir
stli
net r
eatmentsforGAD. Bupropi o
na nd
Pregabali
na ref
urtherc ho i
ces.
Lo wdo sebenzo dia
zepinescanbeus edbutde pendenceisapr o
blem.
Buspironeha salowa bus epotent
ialandislesss e
dati
ngt hanbenzodiazepines .
• Buspirone: 5mgbi d-ti
d, upto60mg /
day
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• Pre
gabali
n:I nit
ial150mg/dayin2-3divi
deddos
es,
ma ybeinc
rea
sedt
o150mgbi daft
er1we
eki
f
nec
essar
y
• Bupropi
on( Well
butrin,
Zyban):Use:Smokingc
ess
ati
on,se
condli
neAnti
depr
ess
ant.
Anti
depres
sant:
Sta r
t100mgbi dx4da y
s 100m gt i
d.

Obs
ess
ive
-compul
si
vedi
sor
der(
OCD)

• OCD inv olvesrecur r

ingunpleasa
ntt houghts(obses
sions)and/orrepet
iti
vebeha vi
ours(compulsi
ons)
.
Thethoug htsma ybec onnecte
dtot herepetit
ivebehaviours
.Fo rex
a mple
, peopl
ewhof e
argetti
ngan
i
nfec
tionma yc onstantl
ywa shtheirhands.Attime s
,ho wever
, t
here
'snoc onnecti
ona tal
lbetweenthe
t
houghtsandt hebe hav i
our
s.
• CBTi stheps ycho therapyofchoice.SSRIs: Fluoxet
ine,Fluvoxamine,Paroxe
tineandSe rt
ral
ine,i
n
t
heusuala nti
de pre s
santdosi
ngr angearethedr ugsofcho i
ceinCa nada.Itmayt ake6-8we e
k sf
or
sy
mptomst oimpr ove.Seco
ndl i
nedr ugsincl
udeCl omi pra
mi ne,Venla
faxi
ne,Ci t
al
o pra
ma nd
Mirt
azapine.

Pos
t-t
rauma
tics
tre
ssdi
sor
der(
PTSD)

• PTSD i sassoc
iat
edwi the x
tremea nxie
tythata ppea
rsaft
erat ra
uma t
icexper
ience.
Sy mptomsusual
ly
st
artwithin3mo nthso fthetra uma t
iceventbutma ytakeye ar
stostar
t.PTSD canbea s
soc
iat
edwith
sl
eeppro bl
e ms
,nightma r
es,i
rritabili
ty,
anda nge r
.Fee
li
ngso fguil
tandunwo rthi
nessarecommo nwit
h
PTSD. Tr aumati
cex per
iencest hatcantriggerPTSD includewa rs
,planecr
ashes,
na t
uraldi
sas
ter
s
(e
.g.
,hur ri
cane
,earthquake),andv iole
ntc r
ime s(e.
g.
,rape,abuse)
.
• SSRIa ndSNRIa ntidepr
e s
sant sha v
ebe enshownt obee f
fecti
veinreduci
ngthesympt omsofPTSD.
Fluox
etine,Parox
etine,Sert
ralinea ndVe nla
faxinear
efirs
tlineoptio
ns.

%(
⌦*✓⌫✓⇥⇤◆

• Deme nti
ai sas eri
ousl os
so fco
gniti
veabi
lit
yinapr evious
lyunimpa i
red
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perso
n, b
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edfr
o m no r
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ifi
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o n,l
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• Themo s
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sanda sma nyas 3⇧⌥⇢✓#✓✓ ⇥⇡
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>(
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Nonpha
rmac
ologi
cal
tre
atment
• Cogniti
vebe
havi
orala
ndi
nte
rpe
rso
nalps
ycho
the
rapya
rea
sef
fec
ti
vea
sant
ide
pre
ssa
ntsi
nmi
ldt
o
mo
derat
edepre
ssi
on.

Pharmacolog i
cal treatme nt
• Ta k eme dicati
onda ily,antidepressantmus tbet a k
e nf or2t o4we eksforeff
ecttobeno t
ice
able.
Me dic
a ti
o nmus tbet ak ene venifpa tientisf eel
ingbe t
ter.
SSRI
• Pa r oxetine( Paxil):Start20mgqhs ,increase10mge v e
r y2wk s,ma x60mgpe rday.
• Fl uox etine( Proz ac):Start20mgPO qd, avoidi ncreasi
ngmo reo f
tenthanmo nt
hly, max80mgPO pe r
day
• Se rt r
aline( Zo l
o ft):Start50 mgPO qAM, i
nc rease50mge very2we ek s
,ma x200mgpe rday
• Fl uv oxami ne( Luv ox):Start25 mgPO qhsx3da ys- >50 mgPO qhsx7da ys->titrate150-250mg
dailydiv ideddo se sbid.
• Ci ta l
opr am( Celex a):St art20mgPO qd, ma x60mg .
• Es c it
alopr am( Le x apro):St art10 mgPO qd
Monoa mineOx ida seInhi bitor( MAO i nhibi t
or )
:Us einAt ypi
c aldepr e
ssio
n, Refr
actoryde pressi
on.
• I s
oc a
rbox a
z i
d( Ma rplan)–10mgPO bi d,ma x60mgpe rda y.
• Phe nelzine( Na rdi l
)–15mgPO t id, ma x90mgpe rda y.
• Tr a nyl
c ypromi ne( Parna t
e )–10- 40mgpe rda yindi videddo s e
s,ma x60mgpe rda y.
Compl ica t
ion:Hy pe rt
ensiv ecri
sis,Se r
o t
o nins yndrome .Inter
a ct
ionwi t
htyrami nec ontai
ningfoodsto
bea voide ds t
rict
ly.
Ser
otoninNor epine phrineRe upt akeI nhibitors(SNRI )no tus edt heseda ys
• Tr ic y
clicAnt i
de pres s
ant s
: Ami tri
pt yli
ne25mgqhs ,No rtri
pty l
ine(Pame l
or)
S/E: Ant i-cho l
ine rgic–dr ymo uth, constipation,blur r
edv i
si
o n,Anti-hi
staminergic–s edati
on,we i
ght
gain;Se ro t
one r
g i
c–s exua ldy s
function; Or tho s
tatichy potension;Sinustachycardi
a, SVT, Ventr
icul
ar
ta
c hycardi a,Prolong edQTi nterval,hea r
tbl ock; Wi thdrawa lsympt oms.
Ot her: Ve nlafaxine( Effexo r)37.5mgPO o d.

8(
⌦2⇢
) ⇧⇢⇢
Inacutel
ypsychot
icindi
vidual
s,s
hort
-ac
tingpare
nter
alant
ipsyc
ho t
ic
seit
heral
oneo ri
ncombina
tio
n
wi
thapar
ente
ralbenz
odiazepi
nema yberecommended.Liqui
dformulat
ionsofat
ypic
alant
ipsy
cho
tic
sma ybe
us
edasa
na l
te
rnati
vetoint
ramusculari
nje
cti
ons,
Ri s
per
idoneandOl a
nzapinear
eexamples
.

At
ypic
alanti
psychotic
s:
• Cl ozapi
ne–12. 5mgPO qdo rbid,t
itr
atesl
owl
yupwardsininc
reme
ntso
f25-
50mg/
day
Targ
etdo se:300–450mg /
day,
ma x900mg /da
y.
S/E:Agr anul
ocyt
osi
s,Diabet
esme ll
it
us,hy
pert
ri
gly
cer
idemia.
NOT1 s
t
LINEAnt i
-psy
cho t
ic
.Or derweekl
ybl
oodcountsfo
r1 montha
ndt
henq2we
eks
.
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) ◆⇤
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0'

• Ol a
nz a
pine( Zyprexa)–Start5-10mgPO qd, i
ncrea
sei n5mg
↵✓⌥⌅⇧✓⇤⌦ &◆⇡⇥◆⇥⇤ ⌦
inc r
eme ntswe e
klya sto
ler
ated,ma x20mg /day. ✏)⇥⌃⌅⇧⌫✓
S/ E:Mi lds edati
on, i
nsomnia,dizziness
,earl
yAST& ALT . ✓/⌦
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ne s
s,weig
htg ain,increa
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ko fdiabet
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li
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pidemia. ⇥⇢⇤◆"⇤)6⌦
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• Que ti
apine( Seroque l
)–Start25mgPO bi d–t id,i
ncreasein25- ⇣
✓ ◆⇤✓⌃⌦⌅✓◆⇤⇥✓⌦
⇧⇢ ⇧#⇥◆⇢ ✓⌦
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dayi ncreme nts
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✓⇥✓⌦⇢⇧⌃⌥⌫⌦
tid,ma x750mg /day.
S/ E:He ada che,sedati
on,dizzi
nes s
, c
onsti
pa t
ion.
• Ri speri
done( Risperdal
)–St ar
t1mgPO b i
d,slowt i
tr
ation2-4mg
PO da i
lyo rdivideddo se
sbid,ma x16mg /day.
S/ E:Insomni a,
ag i
tati
on,EPS, headache,anxiety
,hyperprol
acte
nemia
,po
s t
uralhy potension,
co nst
ipati
on, dizziness
,weightg a
in.

Ty
pica
lant
ipsyc
hotics
:
• Ha lope
ridol(Hal
dol)
–5-10mgPO,IM,IV.
Ma yr
epe
atq30-60
mins
,ma
x300mgpe
rda
y.
• Fluphena z
ine(pr
oli
xi
n)–2.5mgPO bi
d,max40mgperday
.

S/
E–EXTRAPYRAMI DALSI DEEFFECTS:
Ak inesi
a–t reatwithBe nzt
ropi
ne2mgPO / IM/ IVOD
Dy stonicreact
ion–t re
atwithLo razepamo rbe nztr
opi
ne.
Dy skinesia
Ak athesia–treatwithLo r
azepam, Propranol
o lorDiphenhydramine.
Perioraltremor
Neurol
ept
icma l
ignantSy ndrome–Mus cleri
g i
dity,
tremo r
,del
ir
ium, hig
hf eve
r,di
aphores
is,
hype rt
ens i
on.Disconti
nuedrug .Givesympt oma t
ictr
eat
me ntands upport
iveca
re.Tre
atment
withDa ntrol
eneo rbromocri
ptine.
Tar
divedy
s kinesia–Blink i
ng,l
ipsma cki
ng,sucking,chewing,gr
imace s
,choreoa
thetoi
dmov ement
s,
tonicc ontr
acti
onso fneck/ba c
k .
Trea t
me nt–Cl ozapine.

'(
⌦&⇧⇧⌃⌦
⇢⇤◆"5
✓⌅⇢
⌦;⌦
@⇢✓⌃⌦⇥⌦
⌦
+ ⇧
◆⌅⌦
⌃⇢⇧⌅
⌃✓⌅
(
• Li
thi
umbi carbona t
e–St art300mgPO bi d,t
heninc
reas
eto900–1800mgpe rdaydiv
ideddos
es.
Se
rum l
evel
s–0. 6–1. 2mEq/ l,monit
orRFTs,TFTs.
S/
E:tre
mo r
,po ly
dipsia,hy pothyr
oidi
sm,weig
htgai
n,naus
ea/v
omiti
ng,
dia
rrhea
,at
axia
,sl
urre
dspeec
h,
l
ackofcoor
dina t
ion.
Tr
eat
me ntofLi t
hium to xicit
y:
Discontinuelithium.
Che c
ks erum lithium leve
ls,
BUN, el
ect
rol
yte
s.
IVfluids–No rma lsa
li
ne.
Hemo dial
ysisinc aseLi>2mmo l
/L,coma,s
hock,s
ever
edehy
drat
ion,
dete
rior
ati
on,
unresponsivetot reatment
.
09 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

• Dival
proex(Epival
)300- 1600mg /
dayPO bi d.
MonitorLFTswe e
k l
yx1mo nth,t
henmo nthly.
S/
E: Live
rdysfuncti
on,na us
ea /v
omiti
ng,diarrhea
,a t
a xi
a,drowsi
ness
,tr
emor,
sedat
ion,hai
rlo
ss,
weight
ga
inthromboc yt
openia,neuraltubedef
ectsine a
rlypr egnancy.
• Carbamazepine(Tegretol
)750-3000mg /dayPO t i
d.
MonitorweeklyCBCduet oriskofagra
nul o
c yt
osis.
S/
E: Nausea/
vomi t
ing,hepati
ct oxi
ci
ty,
ataxia,dr
ows iness,co
nfusi
on,ny
sta
gmus,dipl
opia
,tr
ansi
ent
l
eukopeni
a,agranul
o c
ytosis,
dr ugrea
cti
on( SJS),
ne uraltubedefec
tinear
lypr
egnancy.

9(
⌦&✓⌃ ◆⇤⇧⇥⇢
⌦◆⌥⇢⇥⇡⌦
⇢✓⌧⌥◆
⌦⌃)⇢⌥⇥ ⇤⇧⇥
1. Ant
iandr
ogenMe di
cat
ions
• Spi ronol
a ct
one
• Ke t
ocona zo
le
• Fi naste
ride

2. Ant
ihy
per
tensi
ves
• Ce ntr
all
yacti
ngsympat
holyt
ic
s(e.
g.Cloni
dine)
• Pe r
ipher
all
yacti
ngsy
mpa t
holyt
ic
s(e.
g.Guanadrel
)
• Be taBloc
kers
• Thi az
ideDiuret
ic
s

3. Ant
ide
pre
ssa
ntMe dicat
ions
• Se l
ect
iveSero
toninReupta
keI
nhi
bit
ors(
SSRI
)
• Tr i
cycl
icAnti
depres
sant
s
• MAO i nhi
bit
ors

4. Se
da t
ive
-Hy pnoti
cMe di
cat
ions
• Ba rbitur
ate
s
• Be nz odi
azepi
nes

5. Dr
ugAbus
e
• AlcoholAbus e
• Heroina buse
• Ma r
ijuanaa b
use
• Me t
ha done
• Tobaccoa buse

6. Ot
herMe
dic
ati
ons
• Anti
chol
ine
rgicMedi
cati
ons
• Anti
psy
choti
cMe di
cat
ions
• H2Re c
eptorBlo
cker
s
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• Al
cohol
wi t
hdr awal:
• Ta bDi a ze
pam 20mgPO q1- 2hprn.
• Ob s erv
ef or1-2ho ursandr e-as
sess.
• I nj
Thi a mine100mgI Mt hen100mgPO OD x3da ys.
• Ma intai
nhy drat
ion.
• I foralDi a
z e
pam no twelltoler
atedthenswit
chtoI njDiazepam 2-5mgI V/min–ma xi
mum
10-20mgq1h, o
rS/ LLo razepam.
• I fs
e ver
el i
verdysf
unc ti
on, sev
erea s
thma,r
espi
rator
yf a
il
ureo rag
e >65yearspre
sent–
Lora z
epa m PO/SL/ IM 1-4mgq1- 2h.
• Ha llucinati
onpresent–Ha loperi
dol2-5mgI M/ PO q1-4h–ma x5do s
es/dayal
ongwit
h
Diaz e
pa m 20mgx3do sesasseizurepr
ophyla
xis
.
• We r nic
k e’
ssyndrome :Thiamine100mgPO OD x1- 2we e
k s
.
• Ko rsako f
f’
ss y
ndrome :Thia mine100mgPO bi d/t
idx3- 12mo nths.

• Opi
oidIntox i
ca t
ion:
• ABCs
• I VGl ucose
• I njNa loxone( Na r
can)0. 4mg–2 mgI V.
• I ntuba ti
ona ndme cha nicalventi
lat
ionma yber equi
redf
ordec
rea
sedle
velcons
cio
usne
ss.
• Coc
a i
neOv e r
dos e:
• ABCs
• I njDi azepam 2- 5mgI V/ min–ma xi
mum 10- 20mgq1h(t ocontr
ols
eizur
es)
.
• Pr opra nololorlabet
alo ltotreathypertens
ionanda rr
hyt
hmia
.
• Hal
luci
noge ns:LSD, mescali
ne ,psil
o c
ybin,MDMA.
• Sy mpt o matictreat
me nta nds upport
ivec a
re.
• De creaseds t
imulati
on.
• Be nz odiazepinesora ntipsychoti
csmi ghtberequire
d.
• Phe
ncycl
idine :
• Ro om wi thmi nimalstimul ati
on.
• I njDi azepamI Vformus clespasmso rsei
zure
s.
• Ha lope r
idoltosuppre sspsychoticbehavior
.
↵⌥⇤
Cl
ini
calExami
nat
ion
Th
isi
sab
lankp
age
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
8%

"⌃⇧⌫ ⇥◆
⌦⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
ro ducey ourse
lf:“Iam Dr.________,youratte
ndingphysici
anandI'l
lbeexa
miningyo
ut oday
.At
anypo into ftheexaminat
ionyouf ee
lunc o
mf ort
able
, pl
eas
eletmek nowandI'
llst
optheexa
mi na
tio
n
ri
ghtt here.”
• Wa sh/Sa nit
izehands
• Expla i
nt othepa t
ientwhatyoua r
ea bouttodoa ndg ai
ninfo
rme dcons
ent.
• Loo kfo rme dica
lequipment/t
herapi
e s(
e.g.dra
ins,
co l
ost
omy /
il
eost
omyba g
s).
• Verba l
izethes t
epso ft
hee x
aminatio
na ndy ourfi
ndings.
• Usepr ope rdrapi
ngt ec
hniques.

2.
Ins
pec
tion

• Ge neralinspe ctiono ft hepa ti

ent:I spa ti
entc omf or
ta blea trest?Dot heya ppea rtobet achy pnoe i
c?
• Exa minet hepa tie
nt '
sha ndsf o rpr esenc eofk oi
lonhy chi a(ironde fici
e ncy),leuk ony chia
(hypoalbumi ne mi a),c l
ubbi ng( I BD, coeliacdi sease,c
ir rho s
is),palma re ryt
he ma ,ta rsta i
ningo r
Dupuy tren'sc o ntr
a cture.
• Askt hepa tientt oho ldt he i
rha ndso utinf ronto fthe ml ookingf oraa nyt remo ra ndt heng etthe m
toextendt he irwr istsupt owa rdst hec eil
ingk eepingt hef ingerse xtende da ndl oo kfo rf l
apping
(as
terixi
si nhe pati
ce nc epha lopa thy ).
• Exa minet hef ace,che c
kt hec onj unc tiv
af orpa llor.Alsoc heckt hes cleraforj aundi ce. Looka tthe
buccalmuc osaf ora nyo bv i
ousul cerswhi chc ouldbeas igno fCr o hn'sdise ase,B12o rironde f
ici
enc y
.
Alsolo oka tt het ong ue. Ifitisr eda ndf atitc ouldbea no thers i
gno fa na emi a,asc oul dang ular
sto
ma t
iti
s.Che ckstateo fde ntiti
o n–pi gme ntationo fo ralmuc osa(Pe utz-Jeg her'ssy ndrome ) ,
tel
ang ect
a s
ia, candidi asis.
• Exa minet hene ckf ora ne nlar
g edl eftsuprac la
v i
cularly mphno de.Apa l
pabl eenla rgeds upra cl
avicula
r
(Virchow' s
)no dei sk no wna sTr o isier'
sSi gn, ma ybeas ig nofma lig
na nc y
. Vircho w'sno dedr ainsthe
thoraci
cduc ta ndr ece i
ve slymphdr ainagef ro mt heent irea bdo me na swe llast hel eftt hora
x .
The ref
o r
e,e nla r
g e
me nto fthisno dema ys ug gestme tasta ti
cde positsf r
o m ama ligna nc yina nyo f
theseareas.
• Exa minet hec hest,inpa rti
cularl o okf orgy na ecoma stiainme na ndt hepr esenc eo f5o rmo res pider
naevi.The sea rebo ths tig mao flive rpatho logy.
• Inspectthea bdo me na ndc omme nto na nyo bviousab no rma l
itiessuc ha ssca rs,ma ssesa ndpul sations.
Alsono teift he reisa nya bdo mi na ldistension/a sci
tes.Lo okfo rdistende dv eins,striae ,Culle n'
s/Gr ey-
Turne r
'ssigns( pancre ati
tis),Siste rMa ryJ oseph'sno dul e( widespre a
da bdo mi nalc anc er)
8> ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

3.
Pal
pat
ion

• Palpationo fthea bdo me ns ho uldbepe rf

o r
me di na
syst
ema ticwa yus i
ngt he9na me dseg mentso fthe
abdome n: ri
g htandl efthy po cho ndrium, ri
g hta ndl ef
t
fl
ank, righta ndl eftili
a cf ossa, t
heumbi li
c alarea ,t
he
hypocho ndr i
um a ndt hes upr apubi cregion.
• Ifapa tientha spaini no nepa rti
cularareay o us houl
d
star
ta sf arfromt ha tar eaa spo ssi
ble.Thet e nde rarea
shouldbee xamine dlas ta sthe yma ys t
artg uardi ng
ma ki
ngt hee xaminatio nv erydi ff
icult
.
• Init
iale xami na t
ions ho uldbes uperfici
alusingo ne
hand.Onc ey o uha veex ami ne da l
l9a reassupe rfici
all
y,
yousho ulde xaminede e per.Thi sispe r
forme dwi thtwo
hands, oneo nt opo ftheo the r.
• Feelforo rgano meg aly
, pa rt
ic ularl
yo fthel iver,splee
na ndk i
dneys.Palpat
ionfo rtheli
verandspl
eeni
s
simil
ar, bo ths t
art
ingi nt her ighti l
iacf o
ssa. Fo rthelive
r,pr
essupwa rdstowardsther i
ght
hypocho ndr i
um. Yo us ho uldt rytot i
met hepa lpa t
ionwiththepat i
entbreat
hingi nasthispr
esse
s
downo nt hel i
ver
.Ifthel iveri sdistended, i
tsdi stancefro
mt hec o
s t
alma r
g i
ns houldbeno t
ed.
• Palpatingf orthes pl
e eni sa sf orthel ive
rbuti nt hedirect
ionofthele f
thypocho ndri
um. Theedgeof
thesple enwhi chma ybef elti fdistendedi smo reno dul
arthanthel i
ver.
• Tof e
e lf orthek idne ysy o us ho uldpl ac
eo neha ndunde rthepatientintheflankr eg
ionandtheo t
her
hando nt o p.Yous houl dt he nt rytoba ll
o tthek idneybetweenthetwoha nds.

4.
Per
cus
sion

Perc
ussi
onoverthea bdomenisusual
lyres
onant
,overadist
endedli
veri
twil
lbedul
l.Per
cus
sioncanal
so
beusedtocheckfor'shi
fti
ngdull
ness
' -asi
gnofa s
cit
es.
Wi t
ht hepa
tie
ntly
ingf
lat
,sta
rtpe
rcuss
ingfr
om
themidli
neawayfromy o
u.Ift
hepe r
cussi
onnotechanges
,holdyoufi
ngeri
ntha
tposit
ionandaskthe
pati
enttoro
llt
o wardsyou.Agai
npe r
cussove
rthisare
aandifthenotehasc
hange
dthenitsugge
sts
pres
enceoffl
uidsucha si
na s
cit
es.

5.
Aus
cul
tat
ion

Li
st
enwi
tht
hedi
aphra
gm ne
xttotheumbil
ic
usforupto30s e
conds.
Li
st
enf
orbo
wels
ounds–abs
ent(e
.g.I
leus
,per
it
onit
is
),t
ink
ling(bowelo
bst
ruc
ti
on)

6. Youshouldmenti
ontotheexa
mineratt
hispointthatyouwouldl
iketofi
nis
htheexaminat
ionwi
tha
n
examina
tionoft
heherni
alo
rif
ice
s,t
heext
ernalgenital
iaanda
lsoarect
alex
amina
tio
n.Itisal
so
appro
pria
tetoper
for
m auri
nalys
isa
tthi
spointincludi
ngapregnancyte
sti
nfemale
s.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
80

◆⌅
⌃⇧ ◆⇢⌥
◆⌅⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
ro ducey ourse
lf:“Iam Dr.________,youratt
endingphysici
anandI'l
lbeex
aminingyo
ut oday
.At
anypo intoft heexaminat
ionyouf ee
lunc o
mf ort
able
, pl
eas
eletmek nowandI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Sa ni
ti
z ehands
• Expla i
nt othepa t
ientwhatyoua r
ea bouttodoa ndg ai
ninfo
rme dcons
ent.
• Loo kfo rme dic
alequipment/
therapi
e s(
e.g.GTN spra y
,ECG pads,oxy
gen)
• Verba l
izethes t
epso ft
heexaminatio
na ndy ourfi
ndings.

2.
Ins
pec
tion

• Startbyo bservi
ngt hepa tientfromthee ndo ft hebe d. Youshouldnotewhetherthepa t
ientlook
s
comf ort
able.Aret heyc yanosedo rfl
ushe d?
• Respiratoryrate
,rhy thm a nde f
fortofbre athing.
• Che stshape,chestmov eme ntswithrespra t
ion( symme tri
cal/
assymet
rica
l),
skin(sca
rs/nevi)
• Inspectthena il
sfo rclubbing,spli
nterhe mo r
rha ges(infect
iveendocar
diti
s)
,k oi
lonychia(iro
n
defi
c i
encya nemia).
• Inspectfi
ng er
sf orc a
pi l
la
ryr efi
llt
ime, periphe ralcyano si
s,os
ler'
snodes(i
nfect
iveendo c
arditi
s)a
nd
nicoti
nes tai
ning.
• Inspectpalmsf orpa l
ma re ryt
he ma,Janewa yl esionsandx a
ntho mas
.
• Tak etheradialpulse,a s
sessther a
teandr hythm. Att hispo i
nty ous
houldalsocheckforac oll
apsi
ng
pulse–as igno fao rt
icinco mpetence.Lo catet her adi
a lpuls
ea ndpla
ceyourpa l
m overit,thenra
ise
thea r
ma bovethepa tient’
she ad.Ac olla
ps ingpul sewi llpre
sentasakno c
kingony ourpalm.

Atthi
spointyo
ushoul
dsa
ytot
hee
xami
nertha
tyo
uwo
uldl
iket
ota
ket
hebl
oodpr
ess
ure
.The
ywi
ll
us
uall
yte
llyounott
oandgi
vey
out
heva
lue.

• Lookint hee yesforanysignso fja

undi ce(
pa rt
ic
ularl
ybe neaththeuppe reyeli
d),
ana emia(beneat
h
t
helowe re y
elid)andc or
neala r
cus.Yo ushouldalsolooka r
oundt hee y
ef o
ra nyxanthelas
ma .
• Whi l
stlookinga ttheface
,che c
kf ora nyma l
arfacie
s,loo
ki nthemo uthforanysignso fanae
mi asuc
h
asgl
ossit
is,checkthec ol
ouro ftheto ngueforanyc yanos
is,anda roundthemo uthfo ranyangular
st
oma t
iti
s–a nothersi
gno fanae mia.
• Asses
sjug ul
arv enouspress
ure( JVP) ,as
kpa t
ienttoturnthe i
rhea dtolooka wayfromy ou.Lo o
k
acr
ossthene ckbe t
we enthetwohe adso fs
ternocle
idomas t
oidforapul sa
tion.
• Examinet hec hest
,orpraecordi
um f oranyo bviouspuls
ations,a
b normali
tie
so rsc
a r
s,remembe ri
ngto
chec
kt hea xi
llaeaswell.
88 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

3.
Pal
pat
ion

• Pal
pat
ionpraec
ordium t
r y
ingtolocat
et heapexbeata
ndde s
cri
beit
sloc
ati
onanat
omica
lly
.The
nor
ma ll
oca
tionisinthe5thinter
costa
lsspaceinthemid-c
lavi
cul
arl
ine
.
• Pal
pat
eforanyhe a
v e
sorthril
ls
.At hri
llisapalpa
blemurmurwherea
saheavei
sasig
no fl
eft
ve
ntri
cul
arhypert
rophy.Feelf
ortheseallovert
hepraec
ordi
um.

4.
Aus
cul
tat
ion

• Mitra
lvalve–whe retheapexbeatwa sfel
t.
• Tri
cuspi
dv alv
e–o nt hele
ftedgeofthes t
ernuminthe4t
h
int
erc
o s
talspace
.
• Pulmonaryv a
lve–o nthelef
tedgeo fthester
num i
nthe
2ndinter
costals
pace.
• Aorti
cvalve–o nther i
ghtedgeofthes t
ernuminthe2nd
int
erc
o s
talspace
.

Ho wma nyheartsoundsareheard?Ar etheheartsounds

normalincharact
er?Anya bnorma lhear
tsounds?Ifyouhearanyabnormalsoundsyoushoulddes
cribe
themb ywhent heyoccurandthet ypeofsoundtheya r
eproduci
ng.Arether
ea nymurmurs?Ca nyouhear
anyrub?Feeli
ngther a
dialpul
sea tthesamet i
mec ang i
vegoodindi
cat
ionastowhe nthesoundoccurs–
thepuls
eoc c
ursatsyst
o l
e.Fur
thermo re,i
fyoususpectamurmur,chec
kifitra
di a
tes
.Mi t
ralmurmurs
typi
cal
lyradi
atetotheleftaxi
ll
awhe r
easaort
icmurmur sar
eheardoverthel
eftcaro
tidart
ery.

• Tofurtherc
he c
kformitra
lstenosi
syo
uc anl
aythepa
tie
ntont he
irl
eftsi
de, as
kthemt obre
athein,
the
no utandho l
ditoutandli
s t
enovert
heapexandaxi
ll
awiththebello
ft heste
tho
s c
ope.
• Aorti
cincompetenc
ec anbeasses
sedi
nas i
mil
arwaybutaskthepat
ienttos i
tfor
ward,re
peatthe
bre
athein,outandholdexer
ciseandl
ist
enove
rtheaor
ticar
eawiththediaphragm.

5.
Wit
hpa
tie
nts
it
ti
nguppe
rcus
sba
ckf
orpl
eur
ale
ffus
ion(
car
dia
cfa
il
ure
)

6.
Fina
ll
yas
ses
sfo
ranype
dalo
ede
ma.

7.
Fini
shb
ytha
nki
ngt
hepa
tie
nta
nde
nsur
ingt
heya
rec
omf
ort
abl
eandwe
llc
ove
red.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
8'

2✓⌅ ✓⌅
◆⌦
7◆⇢⌥
◆⌅⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
ro ducey ourse
lf:“Iam Dr.________,youratt
endingphysici
anandI'l
lbeex
aminingyo
ut oday
.At
anypo intoft heexaminat
ionyouf ee
lunc o
mf ort
able
, pl
eas
eletmek nowandI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Sa ni
ti
z ehands
• Expla i
nt othepa t
ientwhatyoua r
ea bouttodoa ndg ai
ninfo
rme dcons
ent.
• Loo kfo rme dic
alequipment/
therapi
e s(
e.g.GTN spra y
,ECG pads,oxy
gen)
• Verba l
izethes t
epso ft
heexaminatio
na ndy ourfi
ndings.

2.
Ins
pec
tion

• Ge neralobservati
ono fthepati
ent,armsf romt hef i
ng ertipstothes houlde randleg sfromt hegroi
n
andbut tockstothet oes.Comme nto ntheg ene ra
la ppearanceo fthea rmsa ndle gs
,size,s
we ll
ing,
symme t
ry,ski
nc olor
,ha i
r,s
cars
,pigme ntati
oninc ludinga nyo bviousmus c l
ewa sti
ng.No tecolourand
tex
tureo fna i
ls
.
• Anys ignso fgangreneo rpre
-gangrenes uchasmi ss
ingt oeso rblackeningo fthee x
tremi t
ies.
• Thepr esenceo fanyulcers–ensureyo uc hec
ka lla r
o undt hefeetincludingbe hindthea nk l
e.These
ma ybev enouso rarte
rial–onede f
iningf ac
tori sthatv enousulcerstendt obepa i
nlesswhe reas
art
e r
ialarepainful.
• Anys kinc hangessucha spall
or,
chang einc ol
o ur( e
gpur ple
/blackfrom ha emo sta
siso rbr
o wnf r
om
haemo sideri
nde posit
ion),v
aric
oseec zemao rsiteso fprev i
ousulcers,atr
o phicchang esandha irl
oss
.
• Presenceo fanyv a
ricosevei
ns–o ft
ens ee nbestwi tht hepa t
ientstanding.

3.
Pal
pat
ion

• As s
essthes kint empe rature.Starti
ngdi st
a l
ly
,fee
lwitht heba c
ko fyo urha ndandcompareeachl
imb
totheo the rno tinga nydi ff
e r
enc e
.
• Che ckca pillaryre t
urnb yc ompr essi
ngt hena i
lbeda ndt henrel
easingi t.Normalco
lourshoul
dreturn
within2s e co nds.Ifthisisa bnorma l
,pe r
form Buerge r’
sTest.
Thisi nvo l
vesra
isi
ngthepati
ent’
sfe
e t
to45º. I
nt hepr esenc eofpo o
ra rte
rialsupply,
pall
orr apidl
yde v
elops. Foll
owingthi
s,pl
acethefe
et
overthes ideo fthebe d,c yanosisma ythende vel
op.
• Anyv aricos i
tieswhi chy o uno tedintheo bs
ervat
ions houldnowbepa lpat
ed.Ift
hesear
ehardtothe
touch,orpa infulwhe nt ouc hed,itma ys u
g ges
tthrombophl ebi
tis
.
• Palpatepe riphe ralpulses.The seare:
Ca r otid–o nlypa lpateo neca r
o t
idatatime
Ra di al–us et hepa do fthreefingers
Br ac hial–ma yus ethumbt opa l
pate
Fe mor al–fe elovert heme dialaspectofthei ngui
nalli
game nt.
89 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Popl
ite
a l–askthepati
enttofl
ext heirkne
etor oughly60ºkeepingthe
irfootonthebed,
pl
acebothha ndsonthefro
nto fthek neeandplaceyourfinge
rsinthepo pl
it
eals
pace
.
Post
eri
ort i
bial–fel
tpost
eri
ortot heme di
alma l
leol
uso ftheti
bia.
Dorsal
ispedis–fee
lonthedorsum o fthef
o ot
,la
teraltotheexte
nsortendonofthegre
attoe
.
Yo
usho
uldcompa r
ethe s
eonbo t
hsidesandc o mmentont hei
rstrengt
h.

• Checkforra
dio-
femora
ldela
y.Pa
lpa
tebo
thther
adi
alandfe
mo r
alpul
sesononesi
deofthebo
dy.
The
pul
sat
ionshoul
do c
curatt
hesameti
me.Anydel
aymaysug
gestcoa
rct
ati
onoftheaor
ta.

4.
Aus
cul
tat
ion:
li
st
enf
orf
emo
rala
nda
bdo
mina
lao
rti
cbr
uit
s

5.
Spe
cia
lTe
sts

• Alle
nTe s
t:Askthepati
enttomak eati
g htfi
stande l
eva
tethehand.Occludetheradia
landulnar
art
eri
eswit
hfir
m press
ure.
Theha ndistheno pe
ne d.I
tshoul
da ppea
rbla
nc hed(pall
orcanbe
obser
vedatt
hefing
erna i
ls
).Rel
easeei
thertheUl narorra
dialar
ter
ypres
sureandt hecolorsho
uld
r
e t
urnin7sec
onds.Ift
hepa l
m doesnotreddenimme diat
ely
,thi
ssugge
stsart
eriali
nsuff
ic
iency
.

• St
rai
g htLe gRa i
seandRefil
lTe s
t(Bue
rger
'sTest):Raisetheleg45oto60o
for30secondsunti
l
pa
ll
oro fthef e
etdevel
opsando bser
vee
mptyv ei
ns.Sitthepatie
ntuprightandobser
vet hef
eet.
In
nor
ma lpati
e nt
s,t
hef e
etqui
cklyturnpi
nk(withi
n10- 15s e
c o
nds).I
f,pal
lorpers
is
tsformo r
ethan10-
15
so rthereisdevel
opmentofadus kyc
yanosi
s(rubor),
thissugges
tsofarter
iali
nsuf
fi
ciency
.

• Testf
orincompet
entSaphenousVein:Askthepati
enttos
tandandno t
ethedil
ate
dv ar
icos
evei
ns.
Compresst
hev e
inprox
imallywit
ho nehandandplac
etheotherhand10-15cm di
sta
ll
y.Bri
skl
y
co
mpr e
ssanddecompres
sthedist
alsit
e.Normal
ly,
thehandattheprox
imalsi
teshoul
dfeelno
i
mpulse,ho
we v
erwit
hv ar
icosev
einsatra
nsmitt
edpuls
ema ybefel
t.

• Trendel
enbur gMa neuver(Re t
rogra def i
ll
ing):As kthepa ti
entt oliedo wn.Elevatethele g,a
nd
emptythev ei
nsb yma ss
agingdistaltopr oxima l
.Usingat ourniquet,o ccl
udethes uperf
ici
a lve
insi n
theupperthigh.Askthepa ti
enttos ta nd.Ifthetourni
que tpreventsthev einsfr
o mr e-f
ill
ingrapidly,
thesi
teofthei ncompetentvalvemus tbeab ovethisle
veli.e.
a tthes apheno -
femo ra
ljunction.I
ft he
vei
nsre-fi
ll
,thec ommuni c
a t
ionmus tbel owerdo wn.
Observi
ngt hes a
mepr otocol
,procee ddo wnt heleguntilthet ournique tcont
rolsre-f
ill
ing.As
neces
sar
y,test
:
• abovethekne e-toa ss
esst hemi d-t
highperforato
r
• belowthek nee-toa ss
e ssc ompe te
ncebe t
we enthes horts aphenousv e
ina ndpo pli
tealvei
n
Ifre
-fi
ll
ingc a
nno tbecontroll
ed,thec ommuni cat
ionispro bablyb yoneo rmo r
edi s
talperfora
ting
vei
ns.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
8=

⇠✓⇢ ⌅
◆⇤⇧⌅
)⌦⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
ro ducey ourse
lf:“Iam Dr.________,youratt
endingphysici
anandI'l
lbeex
aminingyo
ut oday
.At
anypo intoft heexaminat
ionyouf ee
lunc o
mf ort
able
, pl
eas
eletmek nowandI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Sa ni
ti
z ehands
• Expla i
nt othepa t
ientwhatyoua r
ea bouttodoa ndg ai
ninfo
rme dcons
ent.
• Loo kfo rme dic
alequipment/
therapi
e s(
e.g.i
nhaler
s,o x
yge
n).
• Verba l
izethes t
epso ft
heexaminatio
na ndy ourfi
ndings.

2.
Ins
pec
tion

• Ge ne r
a llooko fthepa tient.Che ckwhe t
hert heya rec omf o r
tableatrest,i
spatienttachy pnoeic
?Ar e
theyus inga ccessorymus cl
es?Ar et
he r
ea nyo bv i
ousa bno rma l
iti
esoft hechest?Che ckf oranyc l
ues
aroundt hebe ds uchasi nhalers,oxygenma skso rcigare t
te s.
• Inspe cttheha nds ,hot,pinkpe ripheriesma ybeas igno fca r
bo ndioxiderete
ntion.Lo okf oranys i
gns
ofclubbi ng ,cy
a nosis
,hy pertr
ophi cpulmo na ryo st
eoa rthro pat
hy ,
dup ytre
n'scontact
urea ndni coti
ne
sta
ining . Assessforcarbo ndio xideretenti
onf lap/salbuta mo ltremo r
.
• Tak ethepa ti
ent ’
spulse.Af t
ery o uhavet a
k enthepul sei tisadv i
sabl
et okeepy ourhandsi nthesame
positiona nds ubtlycountt hepa ti
ent’
sr es
pirati
o nr ate.
• Inspe ctthef ace,askthepa t
ientt osti
cko utthe i
rt ong uea ndno t
ei t
sc ol
our–c heckingf orc y
anosis
.
-Ho rne r'
ssydro me(Pa nc oas
tt umo ur),plethora( po l
y cythemi a)
.
• Lo okf o ranyus eo faccessorymus c
lessucha sthes t
e rnoc l
e i
doma stoi
dmus c
le.Alsopa lpateforthe
l
e f
ts upr acl
a v
icularnode( Vircho w'
sNo de)asa ne nlarg edno de( Troisi
er'
sSign)ma ys ug ges
t
me tastaticlungc ancer.
• Exa mi net heche standba ck.Obs ervethec hestfora nyde formi t
ies(barr
elchest,kypho scoli
osi
s,
pectuse x cavat
um, pe
ctusc ari
na tum) ,s
y mme tryo fex pans ion,dil
atedv ei
ns,i
ntercosta
lr ecess
ion.

3.
Pal
pat
ion

• Pal
patet
hechest.
Feelbetwee
nt heheadsofthetwoclav
icl
esfo
rthetra
c hea
,seeifi
tisdev
iate
d.
• Feelf
orches
texpans
ion.Pla
ceyo urhandsfi
rmlyontheches
twa l
lwit
hy ourthumbsme e
tinginthe
midli
ne.As
kthepa t
ientt
otakeade epbreat
hina ndnot
ethedist
anceyourthumbsmov eapart
.
Normall
ythi
sshouldbeatleas
t5c enti
me t
res
.Me as
urethi
sattheto
pa ndbo t
tomo ft
helungsaswell
asonthebac
k.
'- ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

4.
Per
cus
sion

• Per
cussionshouldbeperf
ormedonbothsides
,compari
ngsimi l
arar
easonbothsi
des.Star
tbytapping
onthec l
avi
clewhichgi
v e
sanindi
cat
iono ft
hereso
nanceint heape
x.Thenperc
ussno rmal
lyfort
he
ent
irelungfie
lds.Hype
r-res
onanc
ema ysugges
tacoll
apse
dl ungwhereashypo-
res
o nanceordull
ness
sug
ge s
tsconsol
idati
onsuchasi
ninfe
cti
ono ratumour.Besuretoperf
ormthisontheba c
ka swel
l.

5.
Voc
alFr
emi
tus

Chec
kfo
rtact
il
evo
calfr
emit
us.
Plac
ethemedi
ale
dgeofy
ourhandontheche
sta
nda
skt
hepa
tie
ntt
osa
y
‘
99’
.Dothi
swit
hyourhandi
ntheupper
,mi
ddl
eandlo
werar
easofbot
hlungs
.

6.
Aus
cul
tat
ion

• Dothisi
nalla
rea
sofbothlungsa
ndonfro
ntandba
ckcompar
ingthes
idestoeac
hot
her
.Li
st
enf
or
anyr
educe
db r
eat
hsounds,
o ra
ddeds
oundssu
chascr
ack
les
,whee
zesorrhonchi
.

7. Fi
nis
hb yex
amini
ngt
helymphnodesintheheadandnec
k.Star
tundert
hec hi
nwiththesubme nt
al
node
s, moveal
ongt
othesubmandibul
art
hentothebac
ko ft
heheadattheocci
pit
alnodes.
Ne xt
pa
lpat
etheprea
ndpos
tauri
cul
arnodes.
Mov edownthecer
vic
alcha
inandontothesupr
a c
lavi
cula
r
node
s.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
'

✓⇥⇤
⌅◆
⌦↵✓⌅⇧⌥⇢
⌦✏)⇢
⇤✓⌫⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
ro ducey ourse
lf:“Iam Dr.________,youratte
ndingphy si
c i
anandI'l
lbeex
aminingyo
ut oday
.At
anypo intoft heexaminat
ionyouf ee
lunc o
mf ort
able
, plea
seletmek nowandI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Sa ni
ti
z ehands
• Expla i
nt othepa t
ientwhatyoua r
ea bouttodoa ndg aininf
orme dcons
ent.
• Loo kfo rme dic
alequipment/
therapi
e s(
e.g.walk
inga ids)
.
• Verba l
izethes t
epso ft
heexaminatio
na ndy ourfi
nding s
.

2.
Cra
nia
lNe
rveEx
ami
nat
ion

1) TheOl factoryne rve( CN I )iss i

mpl ytest edbyo fferings o me thingf ami li
a rforthepa tientt os me ll
andi dentify–f ore xampl ec offeeo rvine gar.
2) TheOpt i
cne rve( CN I I)ist estedi nfivewa ys:
• Thea cuityi sea sil
yt estedwi thSne l
lenc ha rts.Thi ss ho uldbea ssess
e dbo thwi tht hepa tient
we aringa nyg las seso rco ntactle nsesthe yus uallywe ara ndwi tho utthe m.
• Co l
o urv isioni st estedus ingI sha raplates, the s
ei de ntifypa tientswhoa rec olourbl i
nd.
• Vi sua lfieldsa ret estedb ya skingt hepa ti
e ntt ol ookdi rectlyaty oua ndwi gglingo neo fy our
finge rsine acho fthef ourqua dra nts
. As kt hepa tientt oi dentifywhi chf i
ng eri smov ing.
Vi sua lina tt
ent i
o nc anbet es
te db ymov ingbo thf i
ng ersa tthes amet imea ndc he ckingt he
pa ti
e nti dentifiest his.
• Vi sua lreflexesc o mpr isedi rectandc onc entr i
cr eflexes. Placeo neha ndv erti
callya longt he
no set obl o cka nyl ightf rome nte ri
ngt hee yeno tbe ingt e s
ted. Shi neape nt orchi ntoo nee ye
a ndc he ckt ha tthepupi lso nbo ths i
desc o ns tri
c t
.Thi ssho uldbet es
te do nbo ths ide s.
• Fi nallyf undo sco pys ho uldbepe rfor
me do nbo the yes.
3) Eyemov e me nts :Oc ulomot orne rve( III),Troc hlea rne rve( IV)a ndAbduc e
ntne rve( VI )a re
involvedinmov e
me ntso ft hee ye. Ask i
ngt hepa tientt ok eept he irhe adpe rf
e ctl
ys ti
lldi rectl
yi nf ront
ofyo u,yous ho ulddr awt wol argej oiningH’ sinf ro nto ft hem us ingy ourf i
ng eranda skt he mt o
fol
lowy ourfing erwi t
ht he ire yes.Itisi mpo r
tantt hepa t
ientdo esno tmov et heirhe ad. Alwa y sas kif
thepa ti
ente xpe r
ienc esa nydo ublev isi
o na ndi fs owhe nisi two rse.Als o; l
o okf orpt osisanda ssess
sacc
a dicey emov e me nts.
4) TheTr igemina lne rve( CN V)i sinv olvedi ns enso rys uppl yt ot hef acea ndmo tors uppl yt othe
mus cle
so fma stication. Initiall
yt estthes ensorybr a nc hesb yl ightlyt ouc hingt hef acewi thapi eceo f
cott
o nwo olandt he nwi thabl untpi ni nt hreepl ace so ne achs i
de–a r
o undt heja wline ,ont hec he ek
ando nt hef ore head. Thec o rnealr efl
exs ho ulda ls
obee xami ne da sthes ens o
r ysuppl yt ot hec orne ais
fro
mt hisne rve .Thi sisdo neb yl ightlyto uchingt hec o rneawi tht hec o ttonwo ol.Thi ssho uldc ause
thepa ti
entt os hutt heire yelids.
Forthemo tors uppl y,askt hepa ti
e nttoc lencht he irt eetht og ethe r,obse rvinga ndf eelingt hebul ko f
thema ssetera ndt empo ralismus c l
e s.
The na skt hemt oo pent heirmo ut ha gainstre si
stanc e.Fi nally
perf
o rmt hej awj erko nt hepa tientb ypl acingy ourl e ftinde xf inge ront heirc hina nds trikingi twi th
atendo nha mme r.Thi ss ho uldc aus eslightpr otrusio no ft hej aw.
' ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

5) TheFa cia
l nerv e(CN VI I)suppl iesmo torbr a nchest othemus cl
eso ff aciale xpre ss
ion.The refore,
thisne rveist estedb ya sk i
ngt hepa ti
entt oc reaseupt heirforehe ad( raiset heire yebr o
ws ),cl
o s
ethe ir
eyesa ndk eept hemc loseda g ai
ns tresistanc e,puf foutt heirche eksa nds ho wy out heirteeth.
6) TheVe sti
bul ocochlea rne r
v e(CN VI II)pr ov i
de sinne rvati
o ntot hehe aringa ppa ratusoft heeara nd
canbeus e
dt odi f
ferent i
atec onduc t
ivea nds ens ori
-ne uralhe ari
ngl o s
sus i
ngt heRi nnea ndWe ber
test
s.Fo rtheRi nnet est,placeas oundi ngt uni ngf orko nt hepa t
ient’sma stoidpr o cessandt henne xt
tothe ire a
ra nda skwhi chisl oude r,ano rma lpa ti
entwi l
lfindt hes eco ndpo sitionl ouder.Fo rWe be r
’
s
test
,pl acet hetuni ngf o rkba sedo wni nt hec e ntreo fthepa tient’
sf orehe ada nda ski fitislouderin
eit
he re ar.No rma llyits houldbehe arde qua llyi nbo the ars
.
7) TheGl ossopha r y
ng e alnerv e(CN I X)pr ovide ss e
ns orysuppl ytot hepa late. Itcanbet estedwitht he
gagr eflexo rb yt ouchingt hea r
c heso fthepha rynx .
8) TheVa gusne rv e(CN X)pr ov idesmo to rsuppl yt ot hepha rynx .As kingt hepa t i
entt ospe akgivesa
goo dindi cationt ot hee ffi
cac yo fthemus cles.Yo us houlda lsoo bservet heuv ulabe foreanddur ing
thepa tients aying‘ aah’.Che ckt ha titli
e sc entr al
lya nddo esno tdev i
ateo nmov eme nt.
9) TheAc cessoryne rve( CN XI )g ivesmo tors uppl ytot hes terno c
leido ma sto i
da ndt rapeziusmus cles.
Tot esti t,
a skthepa tienttos hrugt heirs houl de r
sa ndt urnt heirhe ada g ainstr esista
nc e.
10)TheHy pog l
ossa lnerv e(CN XI I)prov idesmo torsuppl ytot hemus cle so fthet ongue .Obs erv
et he
tonguef ora nys ignso fwa stingo rfasci
c ulations .The na skthepa t
ientt os tickt heirtong ueo ut
.Ift he
tonguede viatest oe it
he rside, i
ts ugg e
stsawe a keningo fthemus cl
e so nt ha ts i
de.

3.
Cer
ebe
ll
arEx
ami
nat
ion

Ga
it:
• As kthepa t
ienttos ta
ndup .Obs e
rvethepati
e nt
'spostureandwhe t
hertheya r
es t
eadyo nthe
irfeet
.
• As kthepa t
ienttowa lk,e.
g.totheo t
hersi
deo ftheroo m,andba ck.Ifthepatie
ntno rmall
yusesa
walki
ngaid,all
owt he mtodos o.
• Ob se
rvethediff
erentg ai
tcompo nents(he
elstri
ke,toelif
to f
f).Istheg ai
t
shuff
li
ng/
wa ddli
ng /sci
ssor
ing/swinging?
• Ob se
rvethepati
e ntsarms wingandt ak
eno t
eho wt hepa t
ientturnsarounda sthi
sinvolve
sgoo d
bala
nceandc o-ordinat
ion.
• As kthepa t
ienttowa lkhe e
l-to
-toetoasse
ssba l
ance.
• Pe rf
orm Rombe rg’stes
tb yaski
ngt hepati
enttostanduna i
de dwi t
hhi seyescl
osed.Ifthepat
ient
swaysorl
o s
esbalanc ethi
stestisposi
tiv
e.Standnearthepa tie
nti ncasehef a
lls
.

Co-
ordi
na t
ion:
• Lo o kfo raresti
ngtremo rinthehands .
• Te sttonei nthea r
ms( shoulder
,el
bo w,wrist
)
• Te stfordy sdi
ado c
hokinesisbyshowingt hepatie
ntt oclapb yalt
ernati
ngthepalmaranddo rs
al
sur
faceso ftheo nhand. Asktodot hisasfas
ta spo s
si
bleandr e
peatthete
stwiththeotherhand.
• Pe rformt hefinger-
to-nosetestbyplaci
ngy ourindexfingera bouttwofeetfr
omt hepati
entsfac
e.Ask
himt ot ouchthetipofhi snosewit
hhi sindexf i
ng e
rthent hetipo fyo
urfinge
r.Askhimt odothisas
fas
ta spo ss
ibl
ewhi l
ey ous l
owlymov eyourfinger.Repeatthet es
twi t
htheo t
herhand.
• Pe rformt hehe el
-to-
shint es
t.Havethepa ti
entlyingdo wnf orthisandgethimtorunthehe elofone
footdo wnt heshinoftheo therl
ega ndthent obringthehe elba c
kupt othekneeands t
artagai
n.
Repe atthetestwiththeo therl
eg.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
'%

@ ✓⌅
⌦.⌫"⌦
↵✓⌥⌅
⇧⇧⇡ ◆
⌦⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
roduceyourse
lf:“Iam Dr.________,yourat
tendingphysi
c i
anandI'l
lbeexa
mi ningyoutoday
.At
anypointoftheexaminat
ionyouf ee
lunc o
mf o
rtabl
e,plea
seletmek nowandI'l
lst
o ptheexa
mi na
tio
n
ri
ghtthere
.”
• Wa s
h/Sanit
izehands
• Explai
ntothepa t
ientwhatyoua r
ea bouttodoandg aininf
orme dcons
ent.
• Useproperdrapi
ngt ec
hnique
s ,
verbali
zetheste
pso ftheexa
mi nat
ionandyourfi
ndings.

2.
Ins
pec
tion
• Gener
ali
nspect
ionofpat
ient
:gener
alcomfor
t,a
bnor
ma lpo
stur
e/mov
ements,musc
lewas
ti
ng.
• Theuppe
rbo dysho
uldbee x
posedfo
rthisex
amina
tio
n.Ob s
erv
ethepat
ient
'sar
ms,lo
okfora
ny
musc
lewast
ing,f
asc
icul
ati
on’
sorasy
mme try
.

3.
Tone
• Examinethetoneoft
hemuscl
es.
Sta
r tpr
o x
imallyatt
heshoul
der
,fee
li
ngho weasyt
hejoi
nti
sto
movepassi
vel
y.Thenmovedowntotheelbow,wr i
sta
ndhandjoi
ntsaga
inasse
ssi
ngeac
ho ne
'st
onei
n
t
urn.
• Asse
ssforspa
sticc
atc
h,c
las
p-kni
fer
igidi
ty,l
ed-pipeorc
og-whee
lrig
idi
ty.

4.
Powe
r
• Nex
tass
esst
hepo we ro
fe a
chofthemuscl
egroups
.
– Shoulde
rabduc t
ion(C5)& Shoul
deradduct
ion(
C5/C6/
C7)
– Elbowflex
ion(C5/ C6)& El
bo wext
ensi
on(C7)
– Wr i
stfl
exi
on( C8)& Wr i
stext
ens
ion(C8)
– Fingerf
lex
ion( C8),Fi
nge
rabduct
ion(T1),Fi
ngera
dduc
ti
on(
T1)
– Thumba bduction(C8)

5.
Ref
lex
es
• Therea r
et hreerefl
exesintheuppe rli
mb-t hebiceps,
tri
c epsands upinatorrefl
exes.
• Thebi cepsrefl
ex( C5/C6)istestedbys upporti
ngthepa t
ient'sarm, withitfle
xeda troughl
y60º ,
pl
a c
ingy ourthumbov erthebicepstendona ndhitti
ngy ourthumbwi tht hetendonha mme r.Itis
vi
taltoge tyourpa t
ienttorela
xa smuc ha spossi
bleandfo ryout otakethee ntir
ewe ightoftheirar
m.
• Thet ri
cepsr e
flex(C6/C7)i sel
icit
edb yresti
ngthepa t
ient'sarma cros
st heirchestandhitt
ingt he
tr
icepstendo njustproxi
ma ltotheelbow.
• Finall
y,withthe i
rarmr est
edo ntheirabdo men,locat
ethes upinatortendo n(C5/C6)a sitcrossest
he
ra
dius,placethreefingersonitandhi tthef i
nger
s.Thissho ul
dg ivethes upinat
orr e
fle
x .
Ifyou
st
rugglewi thanyo ftheserefl
exes,
askingt hepat
ienttoclencht hei
rt e
e t
hs houlde x
agg e
rat
et he
re
flex.
'> ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

6.
Sens
ati
on
• Thisi
stes
tedinanumberofway
s.Yo
us ho
uldtes
t
l
ightt
ouch,pi
npric
k,vi
bra
tio
nandjoi
ntposi
ti
on
se
nseandpropri
oce
pti
on.

• As kt hepa ti
entt opl a cethe ira r
msb ythe irs ideswi th
theirpa lmsf acingf or wards. Lig htlyto uc ht hepa tie
nt's
ster
num wi thapi eceo fco t
to nwo o lsot hatt he yk no w
ho wi tfeels
.The n, wi t
ht hepa tient'sey esshut ,li
g htl
y
toucht he i
ra r
m wi tht hec o
t tonwo ol
.Thepl a c
e sto
toucht he ms ho uldt este acho fthede rma to me s.Te ll
thepa t
ienttos a yy ese verytimet he yfe elthec o t
to n
wo ola sitfel
tbe fore.The nr epea tthisus ingal ig htpin
prick.
• Toa ss essvi
bra tiony o usho uldus eas o undi ngt uning
fork.Pl acethef o r
ko nt hepa ti
ent 'ssternum t os ho w
them ho wits ho uldf eel.The npl aceito nthebo ny
promi ne nceatt heba seo fthe irthumba nda skt he mif
itfeelsthes ame . Ifitdo es,the rei snone edt oc he ck
anyhi gher.
Ifi tfee l
sdi fferenty ous houldmov etot he
radialsty l
usandt he nt ot heo lecra nonunt ilitf eels
norma l
.
• Finally,proprio ception. Ho ldt hedi st
alpha lanxo fthet humbo neit
hersi
desotha
tyouc anf
lexthe
interpha la
nge aljoint .Sho wt hepa ti
entt hatwhe ny ouho ldthejo
intext
ende
d,thatr
epres
ents'
Up'
whe reaswhe ny o uho l
di tflexe dt hatre prese nts'Do wn'.Askthepati
entt
ocloset
hei
re y
esand,
havingmov edt hej ointaf e
wt ime sholdi ti no nepo sit
ion-upo rdown.Askthepat
ientwhich
positiont hejointi si n.

7.
Coor
dina
tion
• Pr
onatordri
ft–As kpati
enttoext
endarmsinfr
ontoft
heminsupi
nat
ionandtoc
loset
heire
yes.A
pos
it
iveres
ultoccur
swhe nthearmfal
lsdo
wnwa r
dsandpr
onate
s(c
ere
bralda
mage)
,ince
rebe
lla
r
l
esi
onsthearmsma yri
se.
• Ass
essfordysdi
adocho
k i
nesia
• Ass
essforfi
ngertonosecoordi
nat
ionandint
ent
iona
ltr
emor.

8. Functi
onisaver
yimport
antpa
rtofa
nyneurol
ogic
alexaminat
iona
st hi
sistheare
awhic
hwillaf
fec
t
peopl
e'sda
ytodayli
vest
hemost.
Foruppe
rlimbyo ushoul
daskpeoplet
ot ouc
hthei
rheadwit
hbo t
h
handsandthe
na s
kthemtopic
kupas mal
lobje
ctsuchasacoinwhi
c heachhand.

9. Fi
nis
hbyt
hank
ingt
hepa
tie
nta
nde
nsur
ingt
heya
rec
omf
ort
abl
eandwe
llc
ove
red.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
'0

.⇧!✓⌅
⌦.⌫"⌦
↵✓⌥⌅
⇧⇧⇡ ◆
⌦⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion
• Int
ro ducey oursel
f:“Ia m Dr.
________,youratt
endingphy s
ici
anandI'l
lbee x
aminingyo
ut oday
.At
anypo intoft heexamina t
ionyoufee
lunc o
mf ort
able
, pl
easel
etmek nowa ndI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Saniti
z ehands
• Expla i
nt othepa ti
entwha tyouar
ea bouttodoa ndg ai
ninfor
me dconse
nt .
• Verba l
izethes t
epso ftheexamina
tio
na ndy ourfi
ndings.
• Ma kes urepa ti
entisadequate
lyexpose
d,useproperdr a
pingte
chniques

2.
Ins
pec
tion
• Ob
ser
vet
hepa
tie
nt'
sle
gs,
loo
kfo
ranymus
clewa
sti
ng,f
asc
icul
ati
onso
ras
ymme
try
.

3.
Tone
• Sta
rtbyexa
mi ni
ngtheto
neo fthemuscl
es.Rollthele
go nt
hebedtose
eifitmovese
asi
lyandpull
uponthekneetochecki
tstone.Als
ocheckforank l
eclo
nusbypl
aci
ngthepati
ent
sle
gturned
out
wardsonthebed,movi
ngt heankl
ejo
intafe wtimestor
ela
xita
ndthensharpl
ydors
if
lexi
ngit
.
Anyfurt
hermovementofthejointmays
ugg e
stclonus.

4.
Powe
r
• Nex
tas
ses
sthepowe rofeachoft
hemus cl
egroups.
– Hipflex
ion(L1/L2)& Hi pex
tensi
on(L5/S1)
– Hipabducti
on(L2/ L3)& Hipadduct
ion(L2/L3)
– Kneefle
xion(L5/S1)& Kneeexte
nsio
n( L3/L4)
– Ankledors
ifl
exi
on( L4/L5)& Ankl
eplantarf
lex
ion(
S1/
S2)
– Bigtoefl
exi
on(S1/S2)

5.
Ref
lex
es
• Testthepa ti
ent'
sreflexes.The rear
et hre
er eflexesint helowe rli
mb-t hek neer efl
ex,t
hea nkl
ej e
rk
andthepl antarref
lex-e lici
tedb ystr
o ki
ngupt helateralas
pe ctofthepl anta
rs urfac
e.
• Thek ne erefl
ex(L3/ L4)i stest
edb yplacingt hepa ti
e nt'
slegflexeda tro ughly60º ,t
akingtheentire
weighto fthei
rlegwi thy oura rma ndhittingt hepa t
e ll
artendo nwi ththet endo nha mme r.I
tisvit
al
togety ourpatie
nttor elaxa smuc ha spossibl
ea ndfo ryoutot aket hee ntir
ewe i
ghto fthei
rleg.
• Thea nk l
ejerk(S1/S2)i se l
ici
tedbyr est
ingt hepa ti
e nt'
slego nt hebe dwi t
ht heirhiplate
ral
lyrotat
ed.
Pullthef o
o ti
ntodo rsi
flexiona ndhitthec alcane a
lte ndon.
• Final
ly,withtheirle
go uts t
raightandr e
stingo nthebe d,runt hee ndo ftheha ndleofthet e
ndo n
hamme ralongtheo utsi
deo fthefoot.Thisg ivesthepl antarrefl
ex( S1). Ana bno rmalrefl
exwo ul
ds e
e
thegreattoee xt
ending. Ifyous tr
ug g
lewi tha nyo fthe s
ereflexes,a
s kingt hepa ti
enttoc l
enchtheir
teet
hs houlde xa
ggeratether e
flex
.
'8 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

6.
Sens
ati
on
• Thef ina ltestiss ens ation.Ho we ver,thisiste stedi nanumbe r
ofwa ys.Yo us ho uldt estli
g htt ouch, pinpr ick, vi
br ationa nd
j
o intpo siti
ons e nsea ndpr oprio cepti
o n.
• As kt hepa tientt opl a cethe i
rle gsouts t
raighto nt hebe d.
Lig htlyt ouc ht hepa tient'
ss ternum wi thapi e ceo fc o t
tonwo o
l
sot ha tthe yk no who wi tfeels.The n, wi t
ht hepa ti
e nt'seyes
shut ,lightlyt ouc ht he i
rlegwi tht hec ottonwo ol
. Thepl acesto
touc ht he ms ho ul dt esteac ho fthede rma tome s-ma kesure
youk no wt he se! Te l
lt hepa tienttos a yy eseve rytimet heyf eel
thec o ttonwo ola si tf el
tbe fore.The nr epeatt hisus ingal ight
pinpr ick.
• Toa ssessv ibrationy ous ho uldus eas oundingt uningf ork.
Pla cet hef orko nt hepa t
ient '
ss t
ernum t osho wt he m ho wi t
sho uldf ee l
.The npl ac eito nthe irme dialma lleolusa nda sk
the mi fi tfeelst hes ame .Ifitdo es,the reisnone e dt oc heck
anyhi ghe r.Ifitf eelsdi ff
erenty ousho uldmov et ot het i
bial
epico ndy lea ndt he nt ot heg rea t
ert r
o cha nterunt ilitf eel
s
no rma l.
• Fina ll
y ,propr iocept i
o n. Ho ldt hedi s
t alphala nxo ft heg reattoe
one i
the rs i
des ot haty o uc anf le
xt hei nterpha lang ealjoint.
Sho wt hepa ti
entt ha twhe ny o uho ldt hej ointe xtende d,tha tr
epres
ents'
Up'wherea
swhenyouhol
d
itflexe dt hatr epres ents'Do wn' .
As kt hepa tie nttoc losetheireyesa
nd,havi
ngmov e
dthejo
intaf
ew
time sho lditino nepo si
ti
o n-upo rdo wn.As kthepa t
ientwhi chposi
ti
onthej
ointisi
n.

7. Functi
oni sav e
ryimpo r
tantpar
tofanyne ur
o l
ogicalex
aminati
onasthi
sistheare
awhi c
hwi l
laf
fect
peopl
e'sda ytodayli
vesthemo s
t.Forthelowerlimby oushoul
dass
esst
hepa t
ient'
swalki
ng.Observ
e
thei
rgaita ndchec
kfo ranyabnor
ma l
it
ies.
Whi lsttheyarest
andi
ngyoushouldperfor
m Rombe r
g's
tes
t.Askt hepati
enttostandwit
ht hei
rfee
ta par
ta ndthenclos
ethei
reyes
.Anys wayi
ngma ybe
sugges
tiveo fapos
ter
iorc ol
umnpa t
hology
.

8. Fi
nis
hbyt
hank
ingt
hepa
tie
nta
nde
nsur
ingt
heya
rec
omf
ort
abl
eandwe
llc
ove
red.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
''

&⌥⇢⌥
⇧/⇢
#✓
✓⇤◆
⌦⇢
)⇢⇤
✓⌫⌦
;⌦
✏ ⇥✓4
+◆ #
1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion
• Int
ro ducey ourse
lf:“Iam Dr.________, y
ouratt
endingphysici
anandI'l
lbeex
aminingyo
ut oday
.At
anypo intoft heexaminat
iony oufeeluncomfort
able
, pl
eas
eletmek nowandI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Sa ni
ti
z ehands
• Expla i
nt othepa t
ientwhatyoua reabouttodoa ndg ai
ninfo
rme dcons
ent.
• Ensur epa t
ientisadequat
elyexposed.
• Loo kfo rme dic
alequipment/t
he r
apies
• Showe mpa t
hy .
• Verba l
izethes t
epso ft
heex a
mi nat
iona ndyourfi
ndings.

2.
Ins
pec
tion
• Askforpati
entvit
a l
s
• Observ
epa t
ient:Ispati
entsit
tingcomf o
rtably?Gait
?Posi
ti
onofcomfo
rt.
• Observ
ethepa ti
entfrom behi
nd:
– Pe lvi
cands houlde
rsymme tr
y,pal
patethepe l
vi
cbri
mt oche
ckfors
y mmetr
y.
– Sc oli
osi
s
– Gi bbus(dorsalspi
nesabno rmall
ypromi nent
)
• Observ
epa t
ientfr
o mside:
– Ky pho s
is
– I ncr
easedlumba rl
ordosis
• CheckthespineforSEADS: S:Swelli
ng,E: Eryt
hema,ec
chymosi
s,A:Atr
ophy/
asy
mme
try(
mus
cle
bul
k),D:De f
o r
mity,S:Skinchanges/s
cars/
br ui
si
ng

3.
Rang
eofMot
ion
• Fle
x i
on: Int hes tandingpo si
tionb yask
ingthepa tienttotouchthetoe
s.No r
mal-90o.Thenormal
spi
nes houldleng thenmo rethan5c minthetho r
a ci
ca reaandmo r
ethan7.5cmint hel
umbararea
onforwa r
df lexi
o n.
• Extension: Stabili
z ethepa t
ient,a
skpa t
ienttobe ndba ckwards
.No r
mal–30o.
• Lateralfl
exi
on: askt hepa t
ienttos l
idethei
rha nds t
raightdownthethigh,f
ir
stontheri
ghtandthen
onthel ef
t,keepingt hehipsstrai
ght.
• Obs e
rveforr estr
ictedmov eme ntandlossofsymme t
r y
.
• Testforfacetjointdi sea
se: Askpa ti
enttoextendt heirbackasfa
raspossibl
eandtorota
te(
pain
sug
g est
sfacetjointpa t
hology).

4.
Pal
pat
ion
• Exami
nethebackandpalpa
tef
o ra
rea
sofmuscl
espasma
ndt
ende
rne
ss(
par
aspi
nalmus
cle
s).
• Pa
lpat
espi
nousproce
sse
swiththumbfort
ender
ness
• Sa
croi
li
acj
oint
s,sa
croil
ia
cdimples
,as
kfort
ender
ness
.
'9 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

5.
Anky
los
ings
pondy
li
ti
ste
sts
• Che s
texpansion:Me as
urewithatapeme asur
e(sho
uldbe>5c m)
• Schober'
sTe s
t: Dra
waho riz
ontall
ine10cma boveandone5cm bel
owt hedimplesofVenus(
the
dis
tancebetweenthes
eli
ne ss
houldincr
easeto>20cm duri
nglumbarf
lexio
n–i nank y
los
ing
spondyl
it
isthedist
ancewil
lnotincr
easeto>20cm)
• Distanc
eo ftr
a g
ustowallwhenpati
entissta
ndingwiththei
rbackt
ot hewall(us
efulf
ormo ni
tor
ing
).

6.
Cer
vic
ala
ndt
hor
aci
cmov
eme
nts(
pat
ients
it
ti
ngone
dgeofbe
d)
• Cerv
icalmov eme nts
– Fl exi
on( as kpa ti
enttotouchchintochest)
– Ex tension( a skpati
enttolooktotheceil
ingasfarbackaspo s
sible)
– La teralfl
e xion( a
skpa t
ienttot
ouchtheireartotheshoulderkeepingtheshoulde
rsti
ll
)
– Spur li
ngMa neuver:Extendheadback& br i
nge art
owa r
dssho ulder
.Givegentl
eaxi
alpr
ess
ure
onthehe a d. Ifpat
ientcomplai
nsofpa i
nradia
tingfrom headtoi psi
lat
era
lar
m –di a
gnosi
sof
Radiculopa t
hyi sma de.
– Rot ation( askpa ti
enttolookoverthelef
tandr i
ghtshoulder)
– Pe r
formt hes emov ementspass
ive
lyifact
ivemov ementsarere
stricte
d.
• Thora
cicrotation: as
kpa ti
enttofol
dtheirarmsandt wis
taround.

7.
Tes
tswi
thpa
tie
ntl
yi
ngont
hei
rba
ck
• Strai
ghtlegraisingt est:askthepa tienttoliewi ththes pineo nt hetablea ndtor e l
axc o mpl e
tel
y.
Wi ththekneef ullye x
t e
nde d,fir
sto nelega ndthe ntheo therisslowlylif
teda ndf lex edatt hehip.
Thisproducess tr
e t
cho nthes cia
ticne r
ve,atwhi chpo i
nts ciat
icpa i
nispr oduce d.Ift hisma neuver
producespai
ni nt hehi po rlowba c kwithr adiat
ioni nthes ci
ati
ca rea,t
het estisco nsideredpo sit
ive
fornerverootirrita
tion.Thea ngleo fel
evationo fthelegf ro mt hetableatt hepo intwhe repa i
nis
producedshouldber ecorded.
• FABER( FlexionAbduc ti
onEx ternalRota ti
on): As kt hepa tienttoliesupineo nt hee xamt abl
e.
Placethefooto fthea ffec
teds ideo ntheo ppo si
tek nee
. Pa inint heg r
oina reaindica tesapr oblem
withthehipa ndno tthes pi
ne .Pressdo wng e
ntlybutfirml yont heflexedk neea ndt heo pposit
e
anter
iorsuperi
o rili
acc rest
.Pa inint hesacroil
iacareaindi catesapr obl
em wi t
ht hes acroilia
cjoints
.
• Bo wst
ringtest:Onc ethelev e
lo fpa i
nha sbe enreached, flexthek neeslightlyanda pplyf ir
m pressure
withthethumbi nt hepo pli
tealfossaov erthes t
retchedt ibialnerve.Radiatingpa ina ndpa raes
thesia
e
sugges
tne r
ver oo tir
ritati
on.

8.
Tes
tswi
thpa
tie
ntl
yi
ngont
hei
rabdome
n
• Lasegue'
ssi
gn:Wi t
hpa t
ientsupinea ndhipflexed,
do r
si
fl
exiono ft
hea nklecausespa
inormus cl
e
spasmintheposte
rio
rthighiftherei sl
umba rrootorsci
ati
cne rv
eirr
it
at i
on.
• Femor a
lst
retc
htest:
Wi t
ht hepa t
ientpronea ndtheanter
iorthighfi
xedt othecouch,f
lexeachknee
i
nt urn.
Thiscaus
espaininthea ppropriat
edistr
ibuti
onsbystretc
hingthef emoralner
verootsinL2-
L4.Thepa i
nproducedisnormallya ggr
avate
db ye x
tensi
ono fthehip.
Thet es
tisposi
ti
veifpaini
s
fel
tintheante
rio
rcompa r
tme nto fthig
h.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
'=

3 ⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion
• Int
ro ducey ourself:“Iam Dr.________, y
ouratt
endingphysici
anandI'l
lbeex
aminingyo
ut oday
.At
anypo intoft hee xaminat
iony oufe eluncomfort
able
, pl
eas
eletmek nowandI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Sa ni
ti
z eha nds
• Expla i
nt othepa tientwhatyoua rea bouttodoa ndg ai
ninfo
rme dcons
ent.
• Ensur epa t
ientisa dequat
elyexpo s
e d.
• Loo kfo rme dic
a lequipment/t
he rapies
• Askwhi chhi pispa inf
ul,
showe mpa thy.
• Verba l
izethes t
epso ft
heex a
mi nationa ndyourfi
ndings.

2.
Ins
pec
tionofhi
p(wi
thpa
tie
nts
tandi
ngup)
• Whilet hepati
entisstanding,checkthehipfo
rSEADS: S:Swell
ing,E:Er y
thema ,e
cchymosi
s,
A:Atrophy /
asymme t
ry(mus cl
ebulk),D:Deformit
y,S:Sk i
nchanges(er
ythema /
scars
/abs
cess
/si
nuses
)
• Legleng t
hdiscrepancy
• Whilstthepatientisst
illst
anding,perf
ormtheTr e
ndelenbergtes
t.Thisi
sdo neb yaski
ngthepati
ent
t
oa l
ternate
lystando no neleg.
St a
ndbe hi
ndthepatie
nta ndfee
lthepelvi
s.Itshouldremai
nlevelor
ri
sesl
ightly
.Ifthepe l
visdropsma rke
dlyonthesideoftherais
edleg,t
heni tsugg
estsabduct
ormuscle
weaknessonthel egthepa ti
entisst
andingon.

$K2⇣✏⌦ ⌦ ⌘ $⌦
3.
Gai
t–askpat
ienttowal
ka c
ros
sthef
loo
r.Loo
kfora
nya
bno
rma
li
ti
es,
⇥⇤◆⇡ ⌦ ,⌦$⌅◆⌥⌫◆6 ⌦
hi
p,kne
e, f
ootmovement
s,l
eng
thofst
ri
de. $⌅✓⇥⌃✓✓⇥"✓⌅ ⇡⌦,⌦ !✓◆#⇥✓⇢ ⇢⌦
⇧⌦ ⌦ ◆⌃⌃⌥ ⇤⇧⌅⇢
✓⇢⇤⇥◆⇤⇥⇡⌦ ,⌦ 2◆⌅#⇥⇢ ⇧⇥N⇢⌦
⌦⌃⇢(
3⇡ ⌦ ⇢⇤✓ ⇥⇡⌦ ,⌦ 2⇧⇧6⌦
&✏
3.
Ins
pec
tion& Pa
lpa
tionofhi
p(wi
thpa
tie
ntl
yi
ngdown) ✏⇢ ⇢⇧⌅ ⌦
,⌦ ✏ ◆⇢⇤ ⌦✓⌅✓"⌅ ◆⌦
◆⇢)
• Inspe
cti
onforhipa ndg r
oinswell
ing
s(herni
a,l
ymphade
nopat
hy, ✏⇤⇧⌫ ⇥⇡⌦ ,⌦⌅✓⌃⌅ ✓ N ⇢ ⌦
saphe
nousv a
rix,
eff
usion) ◆⇤◆⌧◆6⌦⇤
◆"✓⇢ ⌦
⌃⇧⌅⇢◆⇢
✏ ◆⇢⇤⌦ ⌦
,⌦ +⌅◆⇥⌦⇤⌥⌫⇧⌅ 6
⌦⇢⇤⌥⌅⇡✓⌦
• Inspe
ctforobvi
ousf i
xedflex
ion !✓"✓⌅ N
⇢6⌦✓⌅✓"⌅◆
⌦◆ ⇢)
• Palpa
teanter
iorhipforlumpsandt e
ndernes
s.
• Palpa
tethegreat
ertrochante
rforanyte
nde r
nes
swhic
hmi g
ht
sugge
sttroc
hanteri
cbur s
iti
s.

4.
Leg
-le
ngt
hdi
ff
ere
nce
• Makeanapproxi
ma t
ejudgmentb yal
igni
ngtheme dia
lma l
leo
liandlooki
ngfordis
crepanc
y.
• Measur
etrueandappare
ntle
g -l
engthi
fa ppr
opri
ate.
Trueleglengt
hdiscr
epa
ncyisfoundb y
meas
uri
ngf r
omt heant
eri
orsuperio
ril
iacspi
netotheme di
alma l
leol
us.
Apparentl
egl e
ngth
di
scr
epanc
yisme as
uredfr
omt heumbilic
ustotheme di
alma l
le
o l
us.
9- ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

5.
Act
ivea
ndpa
ssi
vemov
eme
nts
• Ass
essacti
veflexi
on, e
xtensio
n,abducti
ona nda dducti
on.
– Fl exi
o n:Flexthek neeto90de gre
esandpa ss
ive
lyflexthehipb ypushi
ngt hekneetowar
dsthe
chest
.
– Ex tension:ispe r
forme dbyplaci
ngy ourha ndunde rthepat
ient'sa
nk l
ea ndask
ingthemtopush
yourha ndintothebe d.
• Pa
ssi
velyasses
sinternalande xt
erna
lrotat
iono fthehip( withhi
psa t90ofle
x i
on)
– I nter
na lr
otati
on: perfo
rme dwiththek ne
ef lex
eda ndb yever
tingthek neefori
nter
nalrot
ati
on
– Ex ternalrota
tio
n: performedwiththek neef l
exedandi nve
rti
ngi tf
ore xt
e r
nalr
otat
ion.

6.
Spe
cia
lte
sts
• Thoma ste
st:Pl
aceyourha
ndundert
hepati
ent
'sl
umbars
pinet
ost
opanyl
umbarmove
me nt
sand
ful
lyfl
exoneoft
hehips.Obse
rvet
heothe
rhip,
ifi
tli
ft
sof
fthec
ouc
htheni
tsug
gest
safi
xedfl
exi
on
def
o r
mityoft
hathip
.

• FABER( Flex
ionAbductionExte
rnalRota
tion):Askthepati
enttoliesupi
neo nt
hee x
amt a
ble.
Pla
cethefoo
to ft
heaff
ectedsi
deontheoppo s
it
eknee
.Painintheg r
oinareaindica
tesaprobl
em
wit
hthehipandno tt
hespine
.Pres
sdowng entl
ybutf
irmlyontheflexedkneea ndtheopposi
te
ant
eri
orsupe
riori
li
accre
st.Pa
ininthesa
croi
lia
care
aindic
ate
sapr obl
em wi t
ht hesacr
oil
ia
cjoi
nts.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
9

H⇥✓✓⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion
• Int
ro ducey ourself:“Iam Dr.________, y
o ura t
tendingphy s
ici
anandI'l
lbeex
aminingyo
ut oday
.At
anypo intoft hee xaminat
iony oufeeluncomf ort
able ,pl
easel
etmek nowandI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Sa ni
ti
z eha nds
• Expla i
nt othepa tientwhaty ouareabouttodoa ndg ai
ninfor
me dcons
ent.
• Ensur epa t
ientisa dequat
elyexposed(upt oab ovek nees
).
• Loo kfo rme dicalequipment/ther
apies
• Aska bo utkne elocking,gi
vingwa yandpa in,showe mpathy.
• Verba l
izethes te
pso ft
heex aminat
iona ndy ourfindings.

2.
Ins
pec
tion
• Gai
t: Askthepa t
ienttowa l
kfory ou.
Obs e
rvea nylimpo robvi
ousdef
o r
miti
essucha ss
carsor
musc
lewa st
ing.Che c
ki ft
hepati
e nthasavarus(bo w-l
egged)orval
gus(kno
ck-knees)defor
mi t
y.
Al
soo bse
rvefrom behindtoseeiftherear
eanyo bvi
ouspoplit
eals
well
ingss
ucha saBa ker
'scys
t.
• Whilethepati
entislyingonthebe d,makeag ene r
alobse
r v
ati
on.Lookforsymme t
ry,re
dne s
s,musc
le
was
ti
ng ,s
cars,
rashesorfix
edflex
io ndefo
rmitie
s.

3.
Pal
pat
ion
• Che ckthet empe ratur
eus i
ngtheba c
k sofy o
urha nds,compa r
ingitwitho therpartsofthele
g .
• Palpatethebo r
dero fthepatel
laforanytende r
ness,behindthek neeforanyswe l
lings,al
onga l
lofthe
jo
intlinesf ortendernessanda tt
hepo intofinser
tiono fthepatell
arte
ndo n.Finall
y,ta
pt hepatel
lato
seeifthereisa nye f
fusio
nde eptothepa tel
la.
• La ndmark so fthek ne
e: Tibia
ltuber
o si
ty,pate
ll
artendo n,qua
dricepstendon,me dialandlat
eral
fe
mo ra
lco ndy l
es.
Peripat
ell
ara rea: pushpa t
ell
ame di
all
ya ndr ubri
g htunde r
neaththeme dialface
to fpatel
laandlook
fortenderness(Pa t
ell
ar–f e
mo rals
tres
sSo) .
Joi
ntl i
net enderne s
s:be ndtheknee90o, pal
pa t
eme dialandlateralj
ointl
ine.

4.
Rang
eofMot
ion
• Act
ivefl
exi
ona ndext
ensi
ono fk
nee–Ob serv
eforre
str
ict
edmovementandfo
rdispl
ace
mento
f
pa
tel
la.
• Pa
ssi
vefle
xionandexte
nsionofkne
e–f ee
lforcr
epi
tus.
• Pa
tel
laappre
hensio
ntest–Mov epat
ell
aaroundandobser
vepa
tie
nt'
sfac
eforpai
n.
• St
rai
ghtlegrai
se–ass
essmentofex
tens
orappara
tus
.
9 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

5.
Spe
cia
lte
sts

Te
stst
oDe tec
tAr thri
tis
:
• Cr epi
tus:Crepit
usisthes
ensat
ionthatisfe
ltwhe nroughcart
il
ageorexpose
dbo neisr
ubbinga sthe
kneeisbent.Theexaminerwil
lfe
e l
,andma yhear,t
hisgri
ndingasthekneeisbentbac
ka ndforth.
• De for
mi t
y: Asthekneecart
il
ageiswo r
nawa y
,thekne e
sma ybecomeprogre
ssi
velyknock
- k
needo r
bow-leg
ge d.
• Li mit
edMo ti
on:Therangeofmotiono ft
hekne ety
pical
lybecomesli
mite
di far
thri
ti
s,bonespurs,
andswell
ingpr ev
entsnor
ma lmobil
it
y.

Te
stst
oDe tec
taTornMe ni
scus:
• Jo i
ntLineTende
rness
J
o i
ntli
netender
ne s
sisaverynon-speci
fi
ctestf
orame ni
scustear
.Thear
eaofthemenisc
usisfel
t,
a
ndapo s
it
ivete
stisconsi
dere
dwhe nther
eispai
ninthisarea
.
• Mc Mur ray
'sTe
st
Mc Murray'
ste
stisperf
ormedwi t
ht hepati
entl
yingfl
atonhisbackandtheex
a mi
nerbendingthe
knee.
Ac li
ckisfe
ltoverthemenisc
ust ea
rasthekneeisbr
o ughtf
romful
lfl
exi
o nt
ofullex
tensi
on.

Te
stst
oDe tec
tanACLTe ar:
• La chmanTest
TheLa chmantestist
hebestte
stt odi
agnos
ea nACLtear
.Wit
ht hekneesli
ght
lybent,
theexa
miner
sta
bil
izest
hethi
ghwhi lepul
li
ngt heshi
nforward.
AtornACLall
o wstheshintos
hiftt
oofar
f
o rwar
d.
• Ant er
iorDrawerTest
Thistes
tisal
sope r
for
me dwit
ht hepati
entl
yingfl
ato
nhisba
ck.Thek neeisbe
nt90de g
ree
sandthe
shi
nispulle
dforwardtocheckthes t
abi
li
tyoftheACL.

Te
stst
oDe tec
tOt herLigamentI nj
uries
:
• Po st
eri
orDr awerTest
Thepo s
terio
rdr a
werispe r
formeds i
mila
rlytothea
nteri
ordrawertes
t.Thistestdete
ctsi
njur
ytothe
PCL. Bypus hi
ngthes hi
nba ckward,t
hefuncti
onofthePCLi stest
ed.
• Co ll
ate
ralLigamentStabi
lit
y
Side
-to-s
ides t
abi
li
tyo ft
hek neede t
ect
sproble
mso ft
hecoll
ater
alli
gaments,theMCLa ndLCL.
Wi t
hthepa tie
ntlyi
ngf l
at,
andt hekneeheldsli
ght
lybent
,theshinisshi
ft
e dtoe a
chs i
de.Damag
eto
theLCLo rMCLwi llal
lowthek neeto"openup"exce
ssi
vely
,aproble
mc alle
dv arus(LCL)orval
gus
(MCL)i nstabi
li
ty.

Te
stst
oDe tectKne e
ca pProble ms :
• Pa tel
larGrind
Thepa ti
entliessupinewi t
ht helegextended.Thee xa
mi nerreproducesthepati
ent'
sk neepai
nb y
pushingthek neecapdo wna nda s
k i
ngt hepati
enttoflexhisthighmus cles
.Da magedc a
rti
la
gecan
causeag r
indings ensationcalle
dc re
pitus.
• Pa tel
larTenderness
Thee xaminerc ans l
ightlyli
ftupt hekne ec
apa ndplacedire
c tpre
s s
ureont heundersurfa
ceofthe
kneecap.Bydo ings o,
t heexami nerisl
o oki
ngfo rse
nsiti
vereg i
onso fcar
til
age.
• Pa tel
larApprehension
Thisisas i
gno fanuns tabl
ek neecap.Whi l
ethee xaminerplacespress
ureo nthekneecap,t
hepati
ent
ma ycomplaino fthes ensati
ont hatthek nee
capi sg
o i
ngt o'popo ut'o
fitsg r
oove
.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
9%

⇧⇧⇤
⌦◆⇥⌃⌦⇥#
✓⌦⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
ro ducey ourse
lf:“Iam Dr.________, youra t
tendingphysici
anandI'l
lbeex
aminingyo
ut oday
.At
anypo into ftheexaminat
iony oufeelunc o
mf ort
a bl
e ,pl
eas
eletmek nowandI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.”
• Wa sh/Sa ni
tizehands
• Expla i
nt othepa t
ientwhatyoua reabo uttodoa ndg ai
ninfo
rme dcons
ent.
• Ensur epa t
ientisadequat
elyexposed( uptoab ovek nees
).
• Loo kfo rme dic
alequipment/t
he r
apies
• Aski fpa ti
entisabletobearweight,showe mpa thy.
• Verba l
izethes t
epso ft
heex a
mi nat
iona ndy ourfindings.

2.
Ins
pec
tion

• Ga i
t: watcht hepa tientwa lk
,observ
ingf oranorma lhe e
lstrik
e ,t
oe-offgai
t.Alsol ooka tthe
ali
gnme nto fthet oe sforanyv al
gusorva r
usde f
ormities.Assessabi
lit
yt oweight-be a
ro na ff
ected
si
de .
• Whi lepatienti sstandingc heckthefootarchescheckingf o
rpe scavus(higharches )orpe splanus
(f
latfeet)
.
• Inspecti
ono ft hef ootwi t
hpa ti
entsi
tti
nga ndf e
etov erhanging
– Che ckthef oota ndank l
eforSEADS: S:Swe l
ling,E: Erythema, ec
chymo si
s,
A: Atrophy /
asymme t
ry( muscl
ebulk )
,D: De f
ormi ty
,S: Skinchang e
s/s
cars/
br uis
ing .
– Che ckthes ymme tr
y,nail
s(psor
ias
is),ski
n,toealignme nt,l
ookf ortoecl
awing , j
ointswe l
lingand
planta
ra nddo rsalcal
luses.
• Finall
yy ous ho uldloo katthepatie
nt'
ss hoes,
no t
ea nyune venwe arone it
hersolea ndt heprese nc
eof
anyinso l
es.

3.
Pal
pat
ionofa
nkl
e/f
oot

• Feeleachf
oo tfortempera
ture
,compar
ingittothetempera
tureo ftheres
tofthele
g .
• Feelfordi
st
alpul s
es.
• Squeezeovertheme ta
tars
ophala
ngea
ljoi
ntsobser
vingthepati
ent '
sfacef
oranypain.
• Pal
pa t
eoverthemi dfoo
t,ankl
eandsubta
larjoi
ntli
nesforanytende r
ness
.Feelt
heAc hi
ll
est
endo
n
fo
ra nythi
ckeningo rs
we l
li
ng.Pal
pat
eme dia
landlater
alma l
le
oliforanytender
ness.
9> ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

4.
Rang
eofMot
ion

• Asse
ssallacti
veandmov e
me nt
softhefoot
.Thesemovement
sar
einv
ers
ion,
ever
sio
n,do
rsi
fl
exi
on
andpla
nta r
fle
xion.
– Subt alarjoi
nt–i nve
rsi
onande v
e r
si
on
– Ank lejoi
nt–do rsi
fl
exionandplant
arfl
exi
on
– Bi gto e–do rs
if
lexi
ona ndpla
ntarfl
exi
on
– Mi d-tar
saljoi
nts-whic ha
retes
tedbyfix
ingthea
nklewi
thonef
ootandinv
ert
inga
nde v
ert
ing
theforefootwit
ht heother
.

5.
Spe
cia
lte
sts

• Ankl eAnteri
orDr awerTe st-a ssessesforlate
ra lank l
es prai
n
Patie
ntisseat
ed,stabil
izethet ibiawi thoneha ndwhi l
eg raspinghee landpullingita nte
rior
lywith
theother
.Gr e
a t
ertha n3mm a nteriormov eme ntma ybes ignifi
cant.1c mi ss i
gnifi
cantandi ndic
ate
s
anter
iortal
ofi
bularligamentr upt ure.
Posit
iveTest-laxityinthelig ame ntwi t
he xagge rate
da nt e
riortransl
a t
ion
• Ta l
arTilt
Te s
t-a ssesse
sinteg ri
tyo fthede lt
o i
dl igame nt/l
ateralank l
es pra
in
Patie
ntisseat
ed,stabil
izethel ega ndf ootwhi l
ea dductinga ndinv e
rtingthec alca
neusa pplyav a
rus
forc
e.Thec al
caneusisthena bduc t
e dande vert
e da pplyingav al
gusfo rce.
Posit
iveTest-paino rlaxi
tyi nt hel i
game nt
• Thomps on'sTest-a sses
sesf orAc hilles
'tendonr upture
Patie
ntisprone,squeezetheg astrocnemiusa nds o l
eusmus cle
swhi leno ti
nga nymov e mentatthe
ankleandfoot
Positi
veTest-nomov e
me nto rpl antarf
lexio
na ta l
lindicatesa3r dde greest
raino ftheAc hil
les'
tendon
• PlantarFasci
iti
sTe st-assessesfo rinfl
amma ti
o no fthepl antarfasci
a
Patie
ntissupine,dorsi
fle
xt hea nk leande xte
ndsa lltoesthenpr essint heme dialborderofthepl a
ntar
fasc
ia
Positi
veTest-pa inisconsistentwi thplantarfasc ii
ti
s

Ott
awaAnkler ul
es
Fo
rtak
inganklese
rie
sx-ray
s(APandlat
era
lankl
e)
• X- ra
yi ft
hereispai
nov e
rthemall
eol
arzoneAND t
ende
rne
sso
npa
lpa
tio
noft
hepo
ste
rio
rme
dia
lor
l
at
e r
alma l
leol
usOR
• Patientunabletobearwei
ghti
mme di
atel
yandi
nER.

Fo
rfoo
tse
rie
s(APa ndLa t
era
l f
oot)
• X- r
ayifthereispai
ninmi df
ootzoneAND bo
nyt
ende
rne
ssov
ert
hena
vic
ula
rorba
seo
f5th
metat
ars
alOR
• Una bl
etobe arweightimmedia
tel
yandi
nER
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
90

✏ ⇧⌥
⌃✓⌅
⌦⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
roduceyo urse
lf:“Iam Dr.________,yourat
tendingphysici
anandI '
l
lbee xaminingyoutoday
.At
anypointoft heexaminat
ionyo ufee
lunc omfor
tabl
e,plea
seletmek nowa ndI '
l
lstoptheexa
mi na
tio
n
ri
ghtthere.
”
• Wa s
h/Sa ni
ti
z ehands
• Explai
nt othepa t
ientwhatyoua reabouttodoandg aininfor
me dconse
nt .
• Lookfo rme dica
lequipment/
the r
api
e s
,ensur
epatie
ntisadequatel
ye x
posed.
• Askwhi chsho ul
derispai
nful
. Verba
lizethest
epsoftheex a
minatio
na ndy ourfi
ndings.

2.
Ins
pec
tion

• Star
tbyex po
singt
hej ointa
ndo bse
rvethesho
ulderj
ointl
ooki
ngfr
omt heba
ck,s
idea
ndf r
ontf
or
anyscar
s,def
ormit
ieso rmuscl
ewa s
ting(SEADS).Als
oc o
mparebothsi
desf
orsy
mme t
ry.
• Wi t
hthepa t
ients
tanding,as
kt hepa ti
entt
oplac
ethei
rhandsbehi
ndthei
rheada
ndbehindthe
ir
backando bs
ervef
ora nddeformi t
ies
.

3.
Pal
pat
ion

• Feelove rthejo
intandi tssurr
oundingareasfort
het e
mperatur
eo ft
hejo
intasr
ais
edte
mpe r
aturemay
suggestinfla
mma tionori nfe
cti
onint hejo
int.
• Syste
ma ti
cal
lyfeelal
ongbo t
hsidesofthebo nys
ho ul
derg
irdle
.Star
tatthes
ter
nocl
avi
cul
arj
oint,
worka longthec l
avicl
etot heacromiocl
avi
c ul
arj
oint
• Feelthea cromionandt hena r
oundt hespi
neo ft
hes ca
pul
a.
• Feelthea nter
iorandpo ster
iorjoi
ntline
so fthegl
enohumeralj
ointandf
inal
lyt
hemuscle
saroundthe
j
o i
ntfo ranytenderness
.

4.
Rang
eofMot
ion

• Themov e me ntso fthejointshouldstar

tbe ingpe rf
ormeda c
ti
v e
ly.
• Askt hepa tienttobr ingthe i
rarmf orward( fl
exi
o n)
,bendtheirarma ttheelbowa ndpus hbackwa r
ds
(ex
tens i
o n) ,
• Bringt he irarmo uttot hes i
deandupa bovetheirhead(abducti
o n).Whe ntest
inga dduct
ionper f
orm
thescarft e s
t( Thes carftestisperf
orme dwi ththee l
bowf l
exedto90de g
rees,
placingthepati
ent '
s
hando nt heiro ppo s
itesho ul
derandpus hingba ck,agai
nlookf oranydiscomfort.)
• Rotation
– I nte rnalr ot
a t
ion: Askt hepa t
ienttoplaceha ndsinthesma llofthei
rback,ands l
idethem upt he
bac ka sf araspo ssi
ble.
– Ex terna lrotatio
n: As kpa t
ienttorotatetheirarmsoutwards, k
e e
pingtheelbowsf l
exedandb y
thes ideo fthebo dy.
• Onc ea llo fthe s
emov eme ntshavebe e
npe rformeda ct
ive
ly,yousho ul
dpe r
formt hem pass
ivel
ya nd
fee
lfo ra nyc repituswhi ls
tmov ingthejo i
nts.
98 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

5.
Spe
cia
lTe
sts

Tes
tsf
orRot atorCuf f
i
.Supra
spinatus
• Empt yCa nTe s t(testsinte
grit
yo fSupr as pinatus): Thepa ti
ents ta
ndswi tha rmse xtende datthe
elbowsa nda bduc t
edi nthescapularplanea ndwi ththumbspo intedt othef l
o or.Thee xa minerappli
es
do wnwa rdpre ssuretot hearmsa ndthepa t i
enta ttempt stor esi
st.
Po si
tivetes
t: Pa in,mus cl
ewe aknesso rbo th.
• Apl ey'sScra
tc hTe st-Re achoversho uldert o"scratch"be t
we e ns c
apul a.Me asur etowhi chv e
rtebra
e
thumbc anrea ch.
i
i.
Infr
aspinatus
• Ex ternalRota tionLa gSign:Thee lbo wi spa s
sivel
yf le
x e
dt o90de g rees,
a ndt hes ho ulderisheldat
20de gre
esab duc ti
on( inthescapularpl a
ne )andne arma xima lex t
erna lr
ot at
io nb yt hee xaminer.The
pa t
ientisthena skedt oacti
vel
yma i
nta i
nt hepo s
iti
ono fe xternalrota ti
oni na bduc tiona sthe
ex a
mi nerrel
ea sesthewr i
stwhilema intainings upporto fthel i
mba tt heelbo w. Thes i
gni sposit
ive
whe nal ag,ora ng ul
a rdropoccurs.Thema gnitudeo fthelagi srecor dedtot hene arest5de grees.
i
ii
.Subscapularis
• Ge rbe rLif
t-Of fTest: Withthepa ti
e nt'
sha ndo nthes ma lloft heba ck,thea rmi se xt
ende dand
internall
yrotate d.Thee xaminerthenpa s sivelylif
tst heha ndo ffthes malloft heba ck,placi
ngthe
armi nma xi
ma linternalrot
ati
on.Thee xami nerthenr eleasestheha nd.I ftheha ndf allsontothe
ba c
kbe c
auset hes ubsc a
pular
isisunabl etoma i
nt a
ini nter
na lrota t
ion, t
het estre sultispo si
ti
ve.
Pa t
ientswiths ubs capulari
stear
sha vea ni nc reaseinpa ssi
vee xternalr ota
tiona ndawe ak enedabili
ty
tor e
s i
stint
erna lr ot
ation.

Te
stsf
orShoulderInstabil
it
y
• Appr ehensionSi g
nforAnteriorInst
abi
lit
y: Thet
esti
spe r
for
medbyabduct
ingthes ho
uldert
o90
degr
ees,andt hensl
owlyext
ernall
yrotat
ingthesho
ulde
rt o
wa r
d90degr
ees.Apa t
ientwithante
rio
r-
inf
eri
orinst
a bil
it
ywillus
ual
lybe c
o me"appr
ehensi
ve"e
itherve
rba
ll
yorwit
hdi s
tr
essingfac
ial
expr
essi
ons.

Te
stsf
orSuba cromi a
l I
mpi ngeme nt
• Ne e rImpi ngeme ntSign: Plac
eo neha ndo nthepo ster
io raspec tofthesca
pulatost
abil
iz
ethe
shoulderg i
rdle,a
nd, wi
tht heo t
he rhand,takethepa ti
ent '
sinterna l
lyrot
ate
da r
mb ythewrist
,and
pla
cei tinfullforwardfl
e xi
on.Ifthereisimpingeme nt,thepa t
ientwi l
lre
portpai
nintherangeof70
degreest o120de gre
esoff orwardf l
exi
o nastherotatorc uffcome si
ntocontac
twiththeri
gid
cor
a coacromialarch.
• Ha wkinsI mpinge mentSi gn:Thee xaminerpl
a c
est hepa tient'
sa rmin90de gr
eesoffor
wa r
dflex
ion
andf orceful
lyint
e r
nall
yr ota
testhea rm,bri
ng i
ngtheg r
e atertube ro
sityi
ncontac
twiththelat
eral
acr
o mio n.Apo s
iti
veresultisi
ndi ca
tedifpainisrepr o
duc eddur i
ngtheforc
edinte
rnalrot
ati
on.

Te
stsf
orLongHe ado ftheBiceps
• Spe ed'
sMa neuver:Thepa ti
ent'
se l
bowisflex
ed20de gre
esto30de gr
eeswiththefo r
ear
mi n
supi
nati
ona ndt hearmi nabout60de gr
eesofflex
ion.Thee xa
minerres
ist
sforwardf l
exi
onofthe
arm whil
epa lpati
ngthepatie
nt'sbic
epstendonovertheanter
ioras
pectoftheshoulder.
• Ye rgas
ont est:Thepa ti
ent'
selbowisfl
exedto90de gree
swiththethumbup .for
earmi sinneut
ral
.
Thee x
ami nerg r
aspsthewris
t,resi
st
ingatte
mpt sbythepati
enttoact
ive
lysupinat
et hefor
ear
ma nd
f
lextheelbow. Painsugges
tsbicepst
endoniti
s.
 ⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
9'

⇣
"⇧!⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
ro ducey ourse
lf:“Iam Dr.________,youratt
endingphy si
cia
na ndI '
l
lbee x
aminingyo
ut oday
.At
anypo intoft heexaminat
ionyouf ee
lunc o
mf ort
able,pl
easele
tmek nowa ndI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Sa ni
ti
z ehands
• Expla i
nt othepa t
ientwhatyoua r
ea bouttodoa ndg ai
ninformedc onse
nt .
• Loo kfo rme dic
alequipment/
therapi
e s
,ensur
epa ti
entisadequat
elye x
posed.
• Verba l
izethes t
epso ft
heexaminatio
na ndy ourfi
ndings.

2.
Ins
pec
tion

• SEADS: S:Swel
li
ng,E:Eryt
he ma
,ecc
hymosi
s,A:Atrophy/a
symmetry(
muscl
ebul
k),
D:Defo
rmi
ty
,
S:Ski
nchange
s/s
car
s/br
uis
ing.
Che ckf
orafi
xedfl
exi
onde for
mity
.Lookatt
heunde
rsi
deo
fthe
el
bowstoche
ckforanypso
ria
ticpl
aque
s,c
yst
sorrheuma t
oidnodul
es.

3.
Pal
pat
ion

• Fe
eltheelbow,as
ses
singthejoi
ntt
emperatur
ere l
ati
vetothere
sto fthearm.
• Pal
patet
heo le
crano
npr oce
ssaswel
lasthelat
eralandme di
alepic
o ndyl
esfo
rte
nde
rne
ss(
medi
alf
or
go
lfe
r'se
lbowa ndlat
erforte
nnisel
bow),a
ndc ubit
alfoss
afortenderness
.
• Pal
patej
ointli
newithelbowfle
xedto90ofortenderne
ssandswe l
li
ng .

4.
Rang
eofMot
ion

• Themov e
me ntsatthee l
bowjointareal
lfa
irl
yeas
ytodesc
ribeanda
sse
ss.
Thesea
refl
exi
on,
ex
tensi
on,pronat
iona ndsupi
nation.Oncethe
sehavebe
enasses
seda
cti
vel
ythe
yshoul
dbechec
ked
pas
siv
elyc
he cki
ngfo rpowerandc re
pit
us.
• Tes
tforvarus/val
gusi ns
tabi
li
ty
.

5.
Neur
olog
icalExaminati
onofha nd
Mot or Se
nsory
-Me di
a nnerve(t
humba bducti
on) -Me di
a nnerv
e( pulpo findexf
ing
e r
)
-Ra di
alnerve(wri
stex
tensi
on) -Radialner
ve( 1s
t
do
rsalinte
ros
seousspa
ce)
-Ulnarnerve(fi
ngera
bduc t
ion) -Ulnarnerve(pulpo f5thfi
nger
)

6.
Spe
cia
lTe
sts

• TennisEl
bow:Tenni
sel
bowl
ocal
is
espa
inov
ert
hel
at
era
lepi
condy
le,
par
ti
cul
arl
yona
cti
vee
xte
nsi
on
ofthewri
stwi
tht
heelbo
wbent
.

• Golf
er'
sElbow:Go
lfe
r'
sel
bowpa
inl
oca
li
sesov
ert
heme
dia
lepi
condy
lea
ndi
sma
dewo
rseb
y
f
le
xingthewri
st
.
99 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

3◆⇥⌃⌦
◆⇥⌃⌦
?⌅⇢
⇤⌦⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
ro ducey ourse
lf:“Iam Dr.________,youratt
endingphysici
anandI'l
lbeex
aminingyo
ut oday
.At
anypo intoft heexaminat
ionyouf ee
lunc o
mf ort
able
, pl
eas
eletmek nowandI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Sa ni
ti
z ehands
• Expla i
nt othepa t
ientwhatyoua r
ea bouttodoa ndg ai
ninfo
rme dcons
ent.
• Loo kfo rme dic
alequipment/
therapi
e s
• Verba l
izethes t
epso ft
heexaminatio
na ndy ourfi
ndings.

2.
Ins
pec
tion

• Ins
pectha nds:
– Sk in( rashes,Go t
t ron'spatche
s,nodule
s,Raynaud'sphenomenon,sl
ero
dact
yly
,sc
ars
,sk
in
atr
ophy )
– Na i
ls( pitt
ing,onyc holysi
s,spl
inte
rhaemo r
rhages
, cl
ubbing)
– Mus c l
e s(s
we l
ling, wasti
ng )
– J oi
nt s(swe l
li
ng s,
s ubluxati
o n/devi
ati
ono fwri
st,swanne c
k/Bo ut
onier
e'
sdefor
mit
y,
He berde n'
s/Bo ucha r
d'sno des
,Zde f
ormityofthumb)
– I nspectpa lm( pal
ma re r
ythema ,
pall
or,
cyanosi
s),muscl
ewa st
ing.
• Ins
pectelbo ws:
– Ps oriaticskinlesi
o ns
– Rhe uma t
oidno dul es
– Sc ars

3.
Pal
pat
ion

• Asses
sthet e
mpe ra
tur
eov erthejointareasandc omparethesewiththetemper a
tureofthefo r
ear
m.
• Star
tproximall
yandwo rktowa rdsthefingers,feel
ingtheradia
lpulsesandthewr istjoi
nts
.The nfe
el
themusclebulkinthethenara ndhy pot
he nare minences
.Inthepa l
ms ,
feelforanyt e
ndont hi
ckeni
ng
andasses
sthes e
nsat
ionovert hereleva
nta re
a ssupplie
db ytheradia
l,ul
narandme diannerves.
• Squeezeovertherowofme tacarpophalangealjointswhil
stwa t
chingthepa t
ient'
sfaceforany
dis
comfort.
• Bi-manuall
ypa l
pat
eMCPa ndi nte
rphalangea lj
oints.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
9=

4.
Rang
eofMot
ion

• Askthepa t
ientt ope r
formt hefoll
owingmov ementsi
nt hese
quenc
ement
ionedbel
owandobs
erv
e
fo
rrangeo fmov e ment:
– Ma keaf ist
– Pr onatewr ist
– Ex tendlittlefinger(exte ns
ordigitimini
miisusual
lythef
irs
tte
ndo
ntoruptur
einr
heua
toi
d
art
hriti
s)
– Ex tenda llfingers
• Asse
ssfuncti
o n
– Pi nchg r
ip
– Oppo sit
ion( toucht humbt oe a
chf i
nger
)
– Po we rgrip( askpatientt osqueezeyourfi
nger
s)
– Fr ome nt
'st est(f
orul narne rvepalsy
)
– As kpa ti
entt owritesome t
hing/undoabut ton.
• Asse
sspowe r
– Wr is
te x
te nsion(radialne rv
e)
– Thumba bduc t
ion(me di annerve)
– Fi ngerabduc ti
on(ulna rne r
ve)

5.
Neur
ova
scul
arEx
ami
nat
ion

↵✓⌅✓ ✏✓⇥⇢
◆⇤⇧⇥ &⇧⇤
⇧⌅

&✓⌃◆⇥ .◆⇤✓⌅◆⌦⇧⌅
⇤⇧⇥⇢⌦
⇧⌦⇤✓⌦⌥⌦
⇧⌦⇤✓⌦ ⇠✓⇢⇢
⇤✓⌃⌦◆
⌫◆⌅
⌦◆"⌃⌥ ⇤⇧⇥⌦
⇧⌦⇤✓⌦
⇥⌃✓⌧⌦◆⇥⌃⌦
⌫ ⌃⌃
✓⌦⇥⇡✓⌅
⇢ ⇤⌥⌫"

@
⇥◆⌅ .◆⇤
✓⌅◆
⌦⌥⌦
◆⌅✓◆⇢
⌦⇧⌦
⇤✓⌦
⇤⇤
✓⌦⇥⇡✓⌅ "⌃⌥ ⇤⇧⇥⌦
⇧⌦⇤✓⌦⇥⇡✓⌅
⇢⌦◆⇡◆⇥⇢
⇤⌦
⌅
✓⇢⇢⇤◆⇥ ✓

⇠◆⌃◆ ?✓"⌦⇢ ◆✓⌦

"✓⇤!✓✓⇥⌦
⇤✓⌦
⇤⌥⌫"⌦◆⇥⌃⌦ ?⌅⇢
⇤⌦✓⌧⇤
✓⇥⇢⇧⇥
⇥⌃✓⌧⌦⇥⇡✓⌅⌦
B◆⇥◆⇤
⇧⌫ ◆
⌦
⇢⇥⌥ ⌦
"⇧⌧C

6.
Spe
cia
lTe
sts

• Phal
en'st
est:For
cedfle
xiono
fthewr
is
t,e
ithe
ragai
nstt
heo
the
rha
ndo
rbyt
hee
xami
nerf
or60
se
condswil
lrec
rea
tethesympt
omsofc
arpa
ltunne
lsyndr
ome
.

• Finkels
tei
n'st
estisusedtodiagno
seDe Quer
vain'steno
synovi
ti
s.Pa
tie
ntist
o l
dtofl
ext
hethumb
andc l
enchthefi
stoverthethumbf o
llo
wedbyul nardevi
ati
on.I
fther
eisanincr
eas
edpai
ninthe
radia
lsty
loi
dprocessandalongthelengt
hofthee xt
ensorpol
li
ci
sbrevi
sandabduct
orpo
lli
ci
slong
us
t
e ndons,
thenthetesti
spo s
iti
veforDeQuervai
n ’
ssyndrome.

• Tinel'
ssign: Usetheindexfi
ngertot apovert
hecar
paltunnelatthewris
t.Apos
it
ivetes
tre
sul
ts
whe nthetappingcausesti
ngli
ngo rparest
hesi
aint
heareao ft
heme dianner
vedi
str
ibuti
on,
which
i
ncludesthet humb,indexfi
nger,
andmi ddl
eandla
ter
alhalfoftheringfi
nger
.Aposi
tiv
eTinel
'
ssign
atthewristindic
atescarpa
ltunnelsyndrome.
=- ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

+⌅
✓◆⇢
⇤⌦⇣⌧◆⌫ ⇥◆⇤⇧⇥

• Int
ro ducey oursel
f:“Ia m Dr.
________,youratt
endingphy s
ici
anandI '
llbeex
aminingyoutoday
.At
anypo intoft heexamina t
ionyoufee
lunc o
mf ort
able
, pl
easel
etmek nowa ndI'
llst
optheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Saniti
z ehands
• Expla i
nt othepa ti
entwha tyouar
ea bouttodoa ndg ai
ninfor
me dconsent.
• Verba l
izethes t
epso ftheexamina
tio
na ndy ourfi
ndings.Askwhichsidetheprobl
emis.
• Ma kes urepa ti
entisadequate
lyexpose
d,useproperdr a
pingte
chniques

1.
Gene
ral
Ins
pec
tion(
wit
hpa
tie
nts
it
ti
ngons
ideofbe
d)

• Ins
pectwi t
h:
– Pa tient'sarmb ytheirs
ide
s.
– Pa tient'sarmsbehindthei
rhe a
d(tens
esski
n)
– Pa tient'shandsont hei
rhips(t
ens
espect
oral
ismajor
)
Thesema no euver
stestf
o rT4dise
ase–inva
sio
no fche
stwal
l/s
kin.
Ins
pec
tfo
r:
– Obv iousma s
ses
– Sc a r
s
– Ra diotherapytat
toos
– Sk inc ha nges
– Pe a ud'o r
ange
– Di mpl ing
– Ni ppl ere t
rac
ti
on
– Pa g et
'sdi s
ease
.

2.
Ins
pec
tion(
wit
hpa
tie
ntl
yi
ngdown)

– Ins
pecti
nframamma r yf
olds
– Pal
patenormalbreas
tf o
llowedbyabnormalbre
ast
– Pal
pateal
lquadrants
, ni
ppleandaxi
ll
arytai
lofeac
hbrea
st.
– Descr
ibeanyma sse
s: posi
tio
n,si
zeshape,
mo bi
li
ty
,number
,te
nde
rne
ss,
cons
is
tenc
y
– Pal
pateax
ill
aryands upra
clavi
cul
arl
ymphno des.
– Askpati
entaboutdischarge.

3.
Pal
pat
efo
rhe
pat
ome
gal
y.

4.
Axi
ll
arye
xami
nati
on
– Pa l
pat
efora
xil
la
ry,
supr
acl
avi
cul
ara
ndi
nfr
acl
avi
cul
arl
ymphno
des

5.
Aus
cul
tat
elung
s.
⇥ ◆
⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥ ⌦
⌦ ⌦
=

$ )⌅
⇧⌃⌦
⇣⌧◆⌫ ⇥◆⇤⇧⇥

1.
Ste
psbe
for
ebe
ginni
nge
xami
nat
ion

• Int
ro ducey ourse
lf:“Iam Dr.________, y
ouratt
endingphysici
anandI'l
lbeex
aminingyo
ut oday
.At
anypo intoft heexaminat
iony oufeeluncomfort
able
, pl
eas
eletmek nowandI'
lls
toptheexa
mi na
tio
n
ri
ghtt here.
”
• Wa sh/Sa ni
ti
z ehands
• Expla i
nt othepa t
ientwhatyoua reabouttodoa ndg ai
ninfo
rme dcons
ent.
• Ensur epa t
ientisadequat
elyexposed.
• Loo kfo rme dic
alequipment/t
he r
apies
• Showe mpa t
hy .
• Verba l
izethes t
epso ft
heex a
mi nat
iona ndyourfi
ndings.

2.
Ins
pec
tion

• As
kfo
rpa
tie
ntv
ita
ls.

• Obs
erv
epa
tie
nt:
Ispa
tie
nta
nxi
ous
?We
ightg
ain/
los
s?No
teho
ars
ene
sso
fvo
ice
?

• Fe
elpul
se–r
ate
/rhy
thm/
vol
ume

• Fa
ce: Fa ciale xpress
ion(dul linhy po thyroidi
s m)
Periorbitalmy xedema
Losso f1/ 3rdo fey ebrows
Ha i
r–t exture/alo
pe cia
Exo pht halmo s(lookf rom be hindpa tient)
, l
idlag
Opht ha lmo pl
e gi
a( askpa tienttof oll
o wy ourfingerthena s
kfo rdipl
opia)
Che mo si
s(redne s
sa ndwa teringo fey e
s )
• Hands:Tempe rature,mo i
stpa lms ?,texture?color?
Asse s
sf orfinet r
emo rs,palma re y
thema
Pembe rton'ssign-i st hede velopme nto ffacialf
lushing,di
stendedne ckandheadsuper
fi
ci
al
vei
ns ,inspirat
o rystridorande levati
ono fthejugularvenouspre s
sure(JVP)uponrais
ingof
thepa tient'
sbo tha rmsa b
ov ehi s/herhe adsimultaneousl
y.(Tho ra
c i
cinl
etobst
ruct
ion
–e.g .
duet og oit
re)
Carpa lTunne lSyndr ome( Tine l
'sandPha len'
sTe st
)–a ssoc
iatedwi t
hhypothyro
idi
sm.
Armr eflexes–br iski nhype rthyro i
dism.
• Neck: Standi nf ronto fthepa t
ient,inspe c
tf orne c
ks well
ings/g
o i
tre
-scars, si
nus e
s ,
dilatedv essels
.
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⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

3.
Exa
mina
tionoft
heThy
roi
dgl
anda
ndc
erv
ica
lly
mphnode
s.

• Swall
owt est
s–As kpa ti
enttoswal
lowwa te
randobser
veformovementofanymass
es.
• Tonguepro t
rus
io n–Thy r
oglos
salcystmoveso
nt o
ngueprot
rusi
on.
• Sta
ndbe hindthepa tientandpalpa
te.Asses
ssi
ze,t
ext
ure,
smoo t
hnes
s,marg
insandmobil
it
yo ft
he
thy
roidgland(includingwhe nswall
owing).
No t
ethete
mpe r
atur
eovergl
andandadj
acents
kin.
• Pal
patecervi
callymphno des.
• Per
cussoversternum –Re t
rost
erna
lg oi
tr
e.
• Auscul
tateforthyroidbruit–Gr av
e'sdis
eas
e.

4.
Exa
mina
tionofl
egs
.

• Pr
etibi
almyxoedema
• Pe
riphera
ledemaduetocong
esti
vec
ardi
acfa
il
ure.
• Del
a ye
drela
xati
onofank
lere
fle
xinhypot
hyroi
dis
m.

5.
Tha
nkt
hepa
tie
nta
fte
rthee
xami
nat
ion.
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Acandi
dateg
ets2minut
esout
sidet
hest
ati
ontor
eadthec
li
nic
alc
ases
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rioo
nthedo
orbe
for
eent
eri
ng.
Iti
s
e
sse
ntia
ltoge
tyour
sel
forga
nis
edinthe
se2minut
es.

• Rea
dtheque
stio
npr o
per
ly
, unde
rst
andthere
qui
rementandf
oll
owins
truc
ti
ons(e.
g.i
fyo
uar
eas
ked
t
odoaphysi
calexa
minat
ion,donotst
artt
aki
nghist
ory
.Youwil
lbel
osi
ngv a
lua
bleti
me)

• Yo
uwi l
lbegi
ve nape nci
la ndabo o
kletwi
thbla
nkpa ge
s.I
tisag
oodpr
act
ic
etoj
otdo
wnno
tes
.
• Writethena
me ,a
gea ndc hiefc
omplainto
fthepat
ient.
• Forhist
oryofpresentill
ness,yo
uc a
nus et
hemne mo ni
cOCDPQRSTUV+AAA.
• Pa
s tandSoc
ialHi sto
r y:PAM HUGSFOSS
• Writedowny ourdiff
erentialdi
agnosi
s.

Soy
ourno
tes
houl
dlo
oks
ome
thi
ngl
iket
his:

Na
meo
fthepa
tie
nt,
agea
ndc
hie
fco
mpl
ai
nts

O -Onset P–Pastme di
calhist
ory
C-Co urse A-Allergies
D -Duratio
n M -Me dicati
on
P-Place H –Hos pit
a l
iz
ati
ons
Q -Qualit
y U–Ur i
na ryproblems
R-Radia t
ion G –GITpr obl
ems
S-Severit
y S-Sle
ep
T-Timi ng F–Fami lyhistor
y
U–You( As s
oci
atewithyourda
il
yact
ivi
ti
es) O –Obst et
rica
lhist
ory
V–De javu(Ha sithappe
nedbef
ore
?) S–Socialhistor
y
A–Ag gravat
ingfactor
s S–Sexua lhist
ory
A–Alleviat
ingfacto
rs
A–As soci
atedsymptoms
Di
ff
ere
nti
aldi
agno
sis:

• Knoc
kthedoorbef
oree
nter
ing
,re
lax,
tak
eadeepbr
eat
h,s
mil
eande
nte
rther
oom wi
thc
onf
ide
nce
.
Handove
rthest
ick
erst
othephys
ici
anexami
ner
.

• Int
roduceyoursel
ftothepat
ient:e.
g.“
Go o dmorning/
aft
ernoon/
eve
ning
,Mr.
/Mi
ss______,
Iam
Dr._____andI '
my ouratt
endingphys
ici
a ntoday
.”
• “So
, Mr./
Mis s_____,whatcomplai
nthasbroughtyouhereto
da y
?”
• Showe mpathy: “
Oh!Ia msorrytohearthat,
Ishallt
rymybe s
ttohelpy
ou.
”
-- ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Da
taCol
le
cti
on:
OCDPQRSTUV+AAA

• Onse t: Whe ndidits t

art?Sudden?Gr adual?
• Cours e:Isitget
tingwo r
se,bett
erorjus tthesame?
• Dura ti
o n:Yousati tst
a r
ted..
...
..
ago, doesitcomea ndg o?Ho woft
endoesitc
ome ?Fo rho
wl ong
do
e sits t
ayeacht i
me ?
• Pl
ac e: Showmee xa c
tlywhe r
eithurts ?
• Qua l
ity: Tel
lmeho wi tfeel
sli
ke?Isi tsharp/bur
ning/dull
/cr
ampy?
• Radiation: Doesitt r
aveltoanywhere ?
• Se
v erity:Onas calefrom 1t o10,with1be ingthemildestand10theworstpa
in,howba disi
t?
• Ti
mi ng: Isi
two rseatapa rti
cul
artimeo ftheday?
• U(Yo u)y ourdail
ya cti
v i
ti
es:Do esitinterfer
einyourda ytodayacti
vi
ti
es?Doesi
tc hangewit
hy o
ur
da
ilya cti
viti
esl
ikepo sture,r
est
,eati
ng ,exerti
on?
• V(De javu):Ha sithappe nedbefor
e ?Whe n?Wha tha ppenedthe
n?Wha tmedic
a t
ion?

• Ag
gr av
atingf actors:Wha tma ke sitwo rse?
• Al
le
v i
ati
ngf a ct
o rs:Wha tma k ei tbe tt
er?
• As
so c
iat
eds y mpt oms: Ha vey ouno ti
ceda nythingt ha toccurswi t
hit?
• A1: As soci
atedc o nst i
tutio nalsympto msl i
k ef ever,shortnessofbreath,cough,nause
a ,
vomi ti
ng ,dia
rrhe a, he ada c
he ,fat
igue( FSCNVD HF)
• A2: As soci
ateds ympt o mst opartic
ulars ys
te m
Re spirat
o r
y: Che stpa in, sho r
tnessofbr eath, cough, sputum, whe e
zing ,r
unnyno s
e,po s
t
nasaldr i
p ,c
ont actwi thi l
lpe rson,nights we ats,que s
tionsf o
rpul mona ryembolis
m( l
e gpain,
l
o ngt ravel
,surg erya ndo cpus einfema les)
CVS: chestpain, o rtho pne a,paroxys
ma lnoc turnaldy spnea,palpit
ati
o ns,t
achy
c a
rdia
.
GI T: painina bdo me n, st
o ol,bowelmov eme nts,vomi ti
ng ,
jaundice
, bloodinstool
s,diet
,
travel
.
Ne urology: hea dac he ,l
o sso fconsciousness, wea kness,paresthes
ias
Hi gherMe ntalFunc ti
o n: o r
ientati
on, me mo r y
,co nsciousness.
Mo tor:we akne sso flimbs .
Sens ory: t
inglings ensa ti
on.
Ce rebell
um : ga i
t, balanc e.
Cr anialNe rves: spe ech, swa ll
owing,v i
sion, he a
ring .

PAM HUGSFOSS

• “
Ok,
Mr.
/Mi
ss_____,
NowIne
edt
oas
kyo
uabo
uty
ourhe
alt
hing
ene
ral
.Ist
hato
kaywi
thy
ou?
”

• Pa
stMedic
alHi
st
ory:
Wha
tot
herme
dic
alpr
obl
emsdoy
ouha
ve?(
Dia
bet
es/
Hype
rte
nsi
on/
Ast
hma/
Canc
er?
)

• Al
le
rgi
es:
Doy
ouha
vea
nya
ll
erg
ies
?Ar
eyo
ual
le
rgi
ctoa
nydr
ugs
?
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⌦ ⌦-

• Me
dic
ati
on:
Doy
out
akeme
dic
ine
satpr
ese
nt?

• Ho
spi
tal
iz
ati
ons:
(me
dic
al/
sur
gic
al/
tra
uma
)

• Ur
ina
rypr
obl
em:

• GI
T:bo
welmov
eme
nts
?

• Sl
eep?

• “Iamg
oingt
oas
kyouafewper
sonalques
ti
onst
hatwil
lhel
pmei
nmydi
agno
sis
.Ist
hato
kaywi
th
yo
u?Le
tmebegi
nbyas
kingy
ouab o
uty o
urfami
lyhe
alt
h.”

• Fa
mil
yhi
st
ory:
simi
la
rco
mpl
ai
tsi
nthef
ami
ly
?Ca
nce
rint
hef
ami
ly
?De
pre
ssi
on?Sui
ci
de?

• Obs
tet
ri
calHi
st
ory:
Whe
nwa
yyo
url
astpa
psme
ar?Wa
sti
tno
rma
l?Anyhi
st
oryo
fSTI
s?

• “
No wIne
edtoa
skyoua
bouty
ours
exua
lhe
alt
h.Wha
tev
ery
out
el
lmewi
llbek
eptc
onf
ide
nti
al
.Is
t
hatok
aywit
hyo
u?”

• Se
xua
lHi
st
ory:
Arey
ouinaphys
ica
lre
lat
ions
hip?Ho
wlo
ng?
Doyoupr
act
is
esaf
esex
?
Anyr
isko
fSTIs?

• Soc
ialHi
st
ory:
Smo
king
,ho
wma
nypa
cks
?Al
coho
l,a
mount
?Re
cre
ati
ona
ldr
ugs
?

• “I
sthe
rea
nyt
hinge
lset
haty
ouwa
ntt
osha
re?
”

• WRAPUP
- ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Ta
mmyRo bbins,
a48year
sol
dla
dypr
ese
ntedwithhear
trac
ingandche
stdi
scomfo
rtf
ort
hepa
st3da
ys.
Ta
keaf o
cusedhist
orya
ndper
for
mfoc
usedphysi
cale
xaminat
ion.
Vi
tal
s:BP-90/ 70mm Hg,HR-146/
min,i
rre
gular
,RR-12/ min,
Temp-37.5°
C

Cli
nical Info: MsTa mmyRo bbinsisaknownhy pe
rte
nsivewit
hCAD f o
rthepast10yea
rs,
whopr es
ente
d
wit
hs udde no nsetofpalpit
ati
o nsandches
tdisco
mf or
tforthepast3days.Hersympto
msa r
ewo r
seni
ngfor
t
hepa st24ho urs
. Sheha sdyspnea.Shehasdi
zzi
nessfort
hepa s
t12ho urs
.Pe da
ledemais2+.Shehad2
ve
sselang io
pl astydo ne5y ea
rsa go
. ECG showsabse
ntPwa v
eswithir
regula
rnarro
wQRSc omple
xes.
Bil
at
e ralbasa lral
e spres
ento nlunga us
cul
tat
ion.
Cli
nical Cas e: AtrialFi
br i
ll
ation

HOPI Pa
stHis
tor
y
• OCD PQRSTUVW +AAA • Doy ouha v
ea nymedic
ali
ll
ness
es?
• Ho wdi di ts tart?Sudde no rg r
adua l
. • Areyo ual
lergi
ctoanymedi
cati
ons?
• Isitgettingwo rse/bettero rnoc hangesi
n • Anys urg
eri
e si
nthepast
?
t
hesympt o ms? • Pasth/orecurr
enti
nfec
ti
ons?
• Dur at
iono fpa l
pitations ?
• As s
ociatedwi thc he stdi s
co mfort? Fa
mi l
yandSoc ial
Hi st
ory
• De sc
ribet het ypeo fche s
tdi s
comf ort
? • Doy o
us mo ke
?Dur at
ion& fre
quency
.
• Doy ouha vec he s
tpa in? • Doy o
uc onsumea l
cohol
?Dur a
tio
n&
• Anys ho rtne sso fbr eath? fr
e quency
.
• Anydi zz i
ne s
s/lighthe adedness? • Doy o
ut akeanyrecr
eat
ionaldr
ugs?
• Anyf ever /coug h/na usea /
vo mit
ing? • Anyf amilyhist
oryofcance
rs/medic
al
• Anyhe mo ptysis? il
lness
e s
?
• Anyc hills/nig hts we ats?
• Anyma lais e/f
a tig
ue /we akness?
• Anys we llingo ffeet?
• Anynumb ne s
s /paresthesias?
• Anyv isua lpr oblems ?
• Anyr eli
e vingf a ctors?
• Anya gg rav ati
ngf actors?
• Anyr ecentt rauma ?
• Listofc urr entme dications/compliance?

Di
ffe
renti
alDiagnosi
s Ma
nage
me nt
At
ri
alfibr
ill
at
ionsecondar
yto: • Tr eatthepr i
ma rycaus
e.
1.Congest
iveheartf
ail
ure
. • Admi tinc ardi
accareunit.
2.Is
chemicheartdis
eas
e. • Ra tec ontr
olb ybetablocker
s,c
a l
ci
um
3.Hyperte
nsion. channelbloc ker
sordigoxin.
4.Thyr
oiddiseas
e. • Ant icoagulatio
nwi thhepari
n,thenwarf
ari
n.
• Rhy t
hm c ontrolbyele
ctroorme di
cal
I
nve
sti
gat
ions car
diove r
si
o n.
• CBC, el
ect
rol
ytes
,gl
uco
se. • As sessStrok eri
skbyusingCHADS2s c
ore.
• LFTs ,RFTs ,
TSH.
• CK, LDH, Cardi
ace
nzymes.
• 12l e
a dECG.
• Ec hocar
dio
g r
am.
• Che stXray.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
&✓⌃ ⇥✓ ⌦
⌦ ⌦-%

Si
monCha r
les
,a20yea
rso
ldma l
epr
ese
ntedtoyourcl
ini
cwithshor
tnes
sofbr
eat
hfo
rthepa
st24ho
urs
.
Ta
keaf o
cus
edhist
orya
ndperf
ormfo
cusedphys
icale
xaminat
ion.
Vi
tal
s:BP-110/80mm Hg,HR–110/min,RR–22/ min,Te
mp–37. 5°
C.

Cli
nicalInfo:MrSimonCha rl
eshasah/oofAsthmasincet
hepast10years
.Her e
centlycl
eanedhi
s
ba
seme nt1da yagoandhisa
sthmasymptomsexace
rbate
d.Heishavingwheezi
ng,chestti
ghtne
ss,
coughand
SOB. Hei scurr
ent
lyoninha
lerswi
thnonightsy
mpt oms.Onexaminati
on,hehasdyspneaandwheezing
pr
esentina l
llungfi
el
ds.
Heha smil
de x
acer
bati
ono fhi
ssympto
msa ndne e
dsonlyoutpati
enttr
eat
me nt.
Cli
nicalCa se:Ast
hma

HOPI Pa
stHistor
y
• OCD PQRSTUVW +AAA • Doy ouhavea st
hma /ot
he ral
ler
gies?
• Ho wdi ditstar
t?Sudde no rg ra
dua l
. • Ar eyouona nyme dic
ati
o nsandc o
mplianc
e?
• I sitget
tingwo rse/betterornoc hangesin • Ar eyoualler
gictoa nyme dicat
ions?
thesympt oms? • Anyho s
pital
izati
onsfora st
hma ?
• Doy ouwa keupi nni ghtwit hshortnessof • H/ oa
nyo therme dica
lil
lness?
breat
h?
• Doy ouha veno isybreathing? Fa
mi l
yandSocia
lHi story
• H/ ofever/
sorethro at
/rash? • Doy ousmo ke?Dur ati
on& f re
quency.
• Anyni ghttimec ough? • Doy ouconsumea l
cohol?Dur at
ion&
• Anys putum pro ductio
n? fre
quency
.
• Anyc hestpa i
nwi thde epins pir
ation? • Doy ouuserec r
eati
onaldrugs?TRAPPED.
• Anyr ecentacti
vitywhi chwo rse
ne dyour • Anyf amilyhistoryofasthma /
all
ergi
es?
symptoms ?
• Anye xpo s
uretoc o l
da i
r/dust/mi t
es?
• Anype tsatho me ?
• Anyc hang e
sinbo wel& ur inaryha bi
ts?
• Anyc ontactwithas i
ckpe rson?
• Anyr ecenttrav
e l?
• Anyr ecurr
ente pisodes?
• Dos ympt omsa ffectyourda ilyact
ivit
ies?

Di
ff
ere
nti
alDia
gnosis Ma
nage
ment
• As thma. • Vent ol
in2- 4puffsMDIq4- 6h.
• Ac utebr
onchit
is
. • Flutica
sone2- 4puffsbid(
Inha l
edster
oids
)
• GERD. • Asthmae ducat
ion:
• Pne umonia
. Inhale
rus e.
Spacerandho ldi
ngc hambe ruse
.
I
nve
sti
gat
ions Sympt om mo nit
oring.
• CBC. Earlyrecognit
iono fex
acerbati
on.
• Pul monaryfunct
iont
est
s. Avoide nvir
onme ntala
ll
ergens.
• Pe akflo
wme t
er. Encasema t
tr
essandpillo
wi n
• Che s
tXr ay
. i
mpe rme abl
ec ov
e r
.
Reducei ndoorhumi di
tyto<50%.
-> ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Lar
ryEdwar
ds,a55year
soldma npr
esent
edwi t
hbl
oodinsput
um a
ndshor
tne
sso
fbr
eat
hfo
rthepa
st5
da
ys.Tak
eafoc
usedhis
tor
ya ndper
for
mf ocuse
dphys
ica
lexami
nat
ion.
Vi
tal
s:BP-160/110mm Hg ,HR-96/min, RR-18/
min,Temp–37.5°
C.

Clini
calInfo:MrLa rryEdwa rdsisaknownhype
r t
ensi
vewhopr ese
ntedwithshor
tnessofbrea
thandblood
insputum for5da y
s.Itisgra
dualinonset
.Hehaschestpainals
o.Nof ev
erorrec
urre
ntpne umonia
. Heis
nonc o
mpl i
a ntwit
hhi sme di
cati
ons.HeisonLos
a r
tan,Aspir
in,Atorv
as,mult
ivi
tamins.
Heha snotta
ken
hisant
i-hype r
tens
ive
sf o
r4we e k
s.Hasparox
ysmalnoct
urnaldyspneaandort
hopnea.
Clini
calCa se:CongestiveHeartFail
ure

HOPI Pa
stHis
tor
y
• OCD PQRSTUVW +AAA • Doy ouha vedia
bet
eso rhyper
tensi
on?
• Ho wdi di tstart?Sudde no rgradual
. • Areyo uona nymedica
tions?
• Isitg ettingwo rse/bettero rnoc hangesi
n • Co mplia
ncewi t
hme di
c a
tio
ns?
t
hes ympt oms ? • Areyo uall
ergi
ctoanyme dica
tions
?
• Dur ationo fblo odi nsput um? • Anys urge
riesi
nthepast?
• Amo unt/c o
loro fbloodo fsputum? • Pasth/orecurr
enti
nfecti
ons?
• Anyo fs ho rt
ne sso fbreath?
• Pre s
enta tresto rwi the xertio
n? Fa
mi l
yandSoc ial
Hi st
ory
• H/ oo rtho pnea ? • Doy o
us mok e
?Dur at
ion& f
requency
.
• H/ opa ro xysma lno cturnaldy spne a
? • Doy o
uc onsumea l
cohol
?Dur a
tio
n&
• Anyc he stpa i
n/ palpitat
ions ? fr
e quency
.
• Ty peo fpa in–s ha r
po rdul l
? • Doy o
uus erecr
eati
onaldr
ugs?TRAPPED.
• Do est hepa i
nr a diat
eo rs ho otanywhere
? • Anyf amilyhist
oryofcanc
ers
/me dic
al
• Se ver
ityo fpaino nas caleo f1-10. il
lness
e s
?
• Doy ours ympt omsc hang ewi thtime?? • Anyf amilyhist
oryofhear
tdise
ase?
• H/ ofe ver /
coug h/ sorethro at/
rash?
• Anyc hills/nights we at
s?
• Anys we lli
ngo ffaceo rfee t?
• Anyc ha ng einwe ight/appe ti
te?
• Anybr uis esont hebo dy?
• Anyt ra umar ece ntl
y?

Di
ff
ere
nti
alDiag
nos i
s Ma
nage
me nt
• Pul monaryEdemaduetoCHF. • Sy mpt o
ma t
ict
reat
me nt.
• Pul monaryembol
ism. • Admi tinc a
rdi
accareunit
.
• Br onc
hiecta
sis
. • I njLasi
x40mgI Vs tat
.
• Dr uginducedcoa
gulo
pat
hy. • Be tablockers& ACEi nhibi
tor
s.
• Pne umonia. • I njMo rphine2-4mgI V.
• Na s
aloxyg e
n.
I
nve
sti
gat
ions • Sub li
ngua lNit
rogl
yceri
nes.
• CBC, el
ect
rol
yte
s,g
luc
ose
. • Po si
tion-45de greeele
vati
onofhea
dend.
• LFTs ,RFTs,
• PT, PTT, I
NR.
• 12l e
a dECG.
• Ec hocar
diogr
am.
• Che stXRa y.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
&✓⌃ ⇥✓ ⌦
⌦ ⌦-0

Ja
ckAlle
n,a65year
sol
dma npr
ese
ntedwi
t hs
uddenonseto
fri
ghta
rm we
akne
ss4ho
ursa
go.
Tak
eaf
ocus
ed
hi
sto
ryandper
formfoc
use
dphysi
cale
xaminat
ion.
Vit
als
:BP-160/90mm Hg,HR-96/ mi
n,RR-12/ min,
Temp–37.5°
C.

Clinic
alInfo:MrJ ackAlle
npresente
dwiths uddeno nsetofr
ightar
m weak
nesswit
hnumb nes
sand
parest
hesi
as4ho ursago.Hehasslurr
ingofspeech,blurri
ngofvis
ionandmil
dheadache.Hehasno
nausea,
vomitingorhea dt
rauma.Nowe akne
sso flowe rli
mbsorlef
tarm.Noinco
nti
ne nc
e.Heishy
per
tens
ive
fo
rt hepast10y e
arsandno ncomplia
nttome dicat
ions .
Clinic
alCa se:Cerebrova
scul
arAt t
ack

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy o
uha vediabet
esorhy pert
ension?
• Ho wdidi ts t
a r
t?Sudde no rg r
adua l
. • Ar eyouo nanyme dic
ati
o ns/
compl i
ance?
• Isitget
tingwo rse/bet t
ero rnoc hange sin • Ar eyoualle
rgictoanyme dicat
ions?
t
hesympt oms ? • Anys urgeri
esinthepast?
• Dur a
tiono fwe ak ness?
• Whe reiswe aknesslo cated? Fa
mi l
yandSoc ial
Hi st
ory
• Isther
ea nya ssociatedpa inint hea rm? • Doy o
us mo ke
?Dur ati
on& f re
que ncy
.
• Anynumb ness/t
ing l
ing /pa r
esthe s
ias? • Doy o
uc onsumea l
cohol?Dur at
ion&
• Anyl i
mita ti
onsi nr i
g hta rm mov eme nts? frequency
.
• Anya bno rma lpo si
ti
o no frighta r
m? • Doy o
uus erecre
ati
onaldrugs?TRAPPED.
• Doy ours ympt omsc ha ng ewi t
ht ime? • Anyf amilyhist
oryofcanc e
rs/me dic
al
• Anyc hang esinv isi
on? ill
ness
e s
?
• Anyc hang esins peec h?
• Anydi f
ficultyswa llowing /dro ol
ingo fs a
li
va?
• Anyhe ada che/tr
a uma ?
• Anywe ak nesso flefta rmo rlowe rli
mbs ?
• Anys ei
zur es?
• Anyc hang esinf acialex pressi
on?
• H/ ofev
er /cough/ sor
et hr oat/rash?
• Anyc hestpa in/shortne sso fbrea t
h?
• Anyc hang esinbo we l& ur inaryha bits?

Di
ff
ere
nti
alDiagnosis Ma
nage
ment
• Ce rebr
ova s
cularAt
tac
k. • Admi tur
gently
.
• Tr ansi
entIschaemi
cAttac
k. • Urg e
ntneurolo
gic
a lc
onsul
t.
• SubAr achnoidHemorrha
ge. • Ne ur
ovit
al
sq1ho url
y.
• Na sa
loxygen.
I
nve
sti
gat
ions • TabAs pi
rin325mgPO OD.
• CBC, ESR, Glucose
. • Bloodpress
urecontrol
.
• Li pidpro
fil
e,RFTs . • Thr o
mbo l
ysist
obedo neonlyi
fpre
sent
ed
• PT, PTT,INR. wi
thin3hoursofonsetofs
ymptoms.
• ECG.
• CT±MRIHe ad.
• Ec ho,
Caroti
ddo ppl
er.
-8 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Al
lanSmith,
a70y e
arsol
dma npre
sente
dwithlig
hthea
dedne
ssanddiz
zine
ssfo
r2da
ys.
Tak
eaf
ocus
ed
hi
st
oryandperf
ormfocus
edphysi
calex
aminat
ion.
Vi
tal
s:BP-110/80mm Hg ,
HR-56/ min,
irr
egul
ar,
RR-12/min,Te
mp–37. 0°
C.

Clini
calInf
o:MrAl l
a nSmi t
hisaknownhypert
ensiv
efort
hepas
t20y e
arsonme di
cat
ions
.Hei s
exper
ienc
ingli
ghtheadednessanddi
zzi
nessfo
rthepast2days
.Hehaspalpi
tat
ionsa
ndmi l
dc he
stpainfor2
weeks.Heisbr
e a
thle
ssone xer
tio
n.Has2+pedaledema.Nofa
int
ingepi
sode.Notra
umar e
centl
y.Nov i
sual
changesorl
imbwe aknes
s .
Hei sonLosa
rta
n,Rami pr
il
,Dig
oxi
n,Ator
vas,Aspi
ri
n,Nexi
um andCa lc
ium.
ECG s howsType2Se condDe gr
eeAVblock.
Clini
calCase:DigoxinToxici
ty

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha v
edi abetesorhy per
tension?
• Ho wdi di ts ta rt?Sudde no rg r
adual
. • Ar eyo ual
lergictoa nyme dic
ati
o ns?
• I sitgettingwo rs e
/ be t
tero rnochangesin • Anys urg
eri
e sinthepa st
?
thesympt o ms ? • Pa s th/orecurrentinfec
tio
ns ?
• Dur a
tiono fdi zzine ss?
• Anyr el
ie vingf ac t
o rs? Fa
mi l
yandSoc i
alHi st
ory
• Anya gg rav atingf a ctors? • Doy ousmo k e
?Dur at
ion& f r
eque ncy
.
• Anye piso deo ff ainting ? • Doy oucons umea lcohol
?Dur a
tion&
• Anywe ak ne ss/ting li
ng /pa rest
hesi
asofli
mb s
? frequency.
• Anyc he stpa in/pa lpitations ? • Doy ouuser ecrea
tionaldrugs?TRAPPED.
• Anys ho rtne sso fbr eath? • Anyf amil
yhi st
o r
yo fcancers
/me dic
al
• Anyv isua lc ha ng es/hea da che? ill
ne s
ses?
• Anyhe a ringl oss/ea rdis cha r
ge?
• Anye xce ssives we a ting?
• Anyf ever /co ug h/vo mi ti
ng ?
• Anya bdo mi na lpa in/ l
os so fappeti
te?
• Anyc ha ng esi nbo we l
/ur inaryhabit
s?
• Anys we llingo fa nk les?
• Doy ours ympt o msv arywi thchangeinhead
posit
ion?
• Li stofc urr entme dic a
tio ns& c ompli
ance?
• Anyc ha ng esi nme dica t
io ns& do s
ages?
• Anyr ecentt rauma ?

Di
ff
ere
nti
alDiagnosis Ma
nage
me nt
• Di goxintoxi
c i
ty
. • Admi ti
nc a
r di
accar
eunit
.
• Ar rhythmia. • St opDigoxin.
• TI A. • St ar
tDig i
bindincaseo
fma s
si
veov
erdo
seo
r
• Anx i
etydiso
rder. re
frac
torytoxici
ty
.
• Me di
ca t
ioninduce
dbr
ady
car
dia
. • Ex ter
nalPace maker
.

I
nve
sti
gat
ions
• Se r
um Digoxinl
evel
.
• CBC, el
ect
rol
yte
s,RFTs.
• I NR/ PTT, g
luco
se.
• ECG, 24hourHo l
te
rmo ni
tor
.
• Ec hocar
dio
gram,Caro
tidDoppl
er
.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
&✓⌃ ⇥✓ ⌦
⌦ ⌦-'

Lis
aGi r
oux,
a25yearso
ldladypr
esent
edwi t
hlu
mpi
nthene
ckf
orthepas
t7da
ys.
Tak
eaf
ocus
edhi
st
ory
andperf
ormfoc
usedphys
ica
lexaminat
ion.
Vit
als
:BP-120/88mm Hg ,HR–96/ mi n,
RR–12/
min,
Temp–38.5°
C.

Cli
nicalInfo:MsLisaGiro
uxnot
iced2lumpsonther i
ghts
ideofherneckbel
owthemandibl
e.Sheha
s
pos
iti
vehi s
toryoff
everf
or5day
s,s
orethro
atandf
ati
g ue.Onexa
mi na
tio
ns hehas2e
nla
rged,t
ender
sub
ma ndibularl
ymphnodes.
Cli
nicalCa se:I
nfe
cti
ousMononucleos
is(
Sor
ethroat)

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha v
edi abetesorhy pert
ension?
• Ho wdi ditsta r
t?Sudde no rg radua l
. • Ar eyo uona nyme di c
ati
o ns?
• Isitg ett
ingwo rse/bett
e ro rnoc ha ngesin • Ar eyo ual
lergictoa nyme dicat
ions?
t
hes ympt oms ? • Anys urg
eri
e sinthepa st?
• Sinceho wl ongha v eyouno ti
c e
dt hel umps? • Pa s th/orecurrentinfect
ions?
• Whe rea r
et hel umpsl oc ated?
• Ho wdo esthel umpsf eellike? Fa
mi l
yandSoc i
alHi st
ory
• Isthe r
ea nypa i
na ssociatedwi tht helumps? • Doy ousmo k e
?Dur ati
on& f re
que ncy
.
• Ty peo fpa i
n-s harpo rdul lpa i
n? • Doy oucons umea lcohol?Dur at
ion&
• Do est hepa inr adi
a t
eo rs ho otanywhe re? frequency.
• Se ver
ityo fpa ino nas caleo f1-10. • Doy ouuser ecrea
tionaldrugs?TRAPPED.
• Doy ours ympt omsc hang ewi thtime ? • Anyf amil
yhi st
o r
yo fcanc e
rs/me dic
al
• H/ of ever/c
o ugh/ s
o rethro at/
rash? ill
ne s
ses?
• Anyc hestpa in/shortnesso fbr e
a t
h?
• Anya bdo mina lpain?
• Anywe aknesso rmy al
gia?
• Anyc hil
ls/nights we at
s?
• Anyc hang einv o i
ce?
• Anyc hang eina ppe ti
te?
• Anyc hang einwe ight?
• Anyc hang esinbo we l& ur i
na r
yha bi
ts?
• Anyc ontactwi thas i
ckpe r
son?
• Re centtravel?

Di
ff
ere
nti
alDiagnosi
s Ma
nage
ment
• I nf
ecti
ousmo nonucl
eosi
s. • Symptoma t
ictre
atment.
• Ac utebacte
ria
lpharyngi
ti
s. • Ma i
ntai
na dequat
ehy dr
ation.
• Ac utevi
ralpharyng
iti
s. • Rest
.
• Ly mpho ma. • Analges
icsforpai
n.
• To xopl
asmo s
is. • Trea
tSt r
eptococ
calpharyngit
is
,ifc
oex
ist
s.
• Avoidacti
vesports
.
I
nve
sti
gat
ions • Ster
oidsusedonlyforse
ve r
esymptoms.
• CBC.
• Mo nospott
est
.
• Thr o
atswabforg
rams
tai
n,c
ult
ure&
s
ensi
ti
vit
y.
-9 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

J
asonHardi
nge,
a26yea
rsolduni
ver
si
tyst
ude
ntwantstodi
scus
sco
nfi
dent
iali
ss
ueswi
thado
cto
r.Ta
ke
f
ocuse
dhist
oryanda
ddr
esshisc
once
rns.
Vi
tal
s:BP-120/88mm Hg,HR-88/ mi
n,RR-12/min,Te
mp-37.5°
C
Cl
inical
Info:MrJ a
sonHa r
dingeishavi
ngdif
fi
cul
tyinma i
ntai
ningerecti
ondur i
ngi nt
erco
urs
efort
hepa
st4
months.Heiscurr
entl
yinamo nogamousrel
ati
ons
hipwithhisgirl
fr
iend.Hei sonPa ro
xeti
nforhi
smood
di
sor
derfor6mo nths.Noothermedic
alil
lne
sse
s.Gir
lfr
iendisv
eryunde rs
tanding.Heha snomorni
ngor
ni
ghttumescence
.Ha snoer
e c
tio
nwi t
hselfs
ti
mulat
ion.Heisveryanxiousaboutthisis
sue.
Cl
inical
Ca se:I
mpot enc
e

HOPI • Se x ualori
e nta tion-
• OCD PQRSTUVW +AAA hete r
osexua l
/ ho mo sex
ua l
/bi s
exua l?
• Ho wdi di tsta r
t?Sudde no rgradua l
. • Cur rentrelatio nship?
• I sitg ettingwo rse/be t
te ro rnoc hang esin • Pe r fo
rma ncea nx i
ety?
thes ympt oms ? • Anys tr
essesi nt her el
ati
o nship?
• Dur a ti
o no fimpo t
e nc e? • Anys tr
essesa tho meo rsc hool?
• Co ur se& f reque ncyo fimpo t
ence? • Se x ualpartne r'sexpe c
tati
o ns?
• De scriptiono fthepr oblem: noe rectiona t • Ar ey ouona nyme dic
ations ?
all
,c anno tsus t
aine r e
c ti
on, ej
aculatet oo • Co mpl ia
nc e/ty peo fme dications–de t
ail
s?
quick lytos atisfypa rtne r?
• Ca nno ta chie veo r
g asmo ro rgas
m wi thout PastHistory
eja
c ulation? • Doy ouha vedi abetesorhy pertension?
• Anyr etro gr
a dee ja
c ulation? • Ar ey ouallerg i
ct oa nyme dica
tio ns?
• Ci rcums tanc esunde rwhi c himpo tenc e • Anys urgeriesi nthepa st?
occur so nlywi thc ertainpa rt
ne r
s,onl yat • Anyt ra
umai nt hepa st
?
certaint ime so rloca ti
o ns,wha tperce ntageof • Pa s th/orec ur r
e ntinfect
ions ?
thet ime ?
• I simpo tenc er el
atedt ol acko fsexua ldesir
e? Fa
mi l
yandSoc i
alHi story
• Pr ese ncea ndf i
rmne sso fmo rningo r • Doy ous mo k e?Dur ati
on& f requenc y
.
noct urna lerections. • Doy ouc ons umea lcohol?Dur ation&
• Ca ns usta i
ne rec
tionswi ths el
fstimul ati
on? frequency.
• As s ociatedpr oblems :a nxietyattac
k s, • Doy ouus er ec reat
ionaldr ugs?TRAPPED.
anhe do nia/de press
io n, perinealorpe riphera
l • Anyf amilyhi sto r
yo fcanc ers/
me dic
a l
numb ne ss,po orpe riphe ralcir
culati
o n. ill
ne s
ses?

Dia
gnosi
s Ma
nage
me nt
I
mpo t
enc
ese
conda
ryt
oant
ide
pre
ssa
nts
. • Co mpl etephy sicalexam.
• Re assurance,couns el
ingbo t
hpa t
ient&
Causesofimpote
nce: (
IMPOTENCE) part
ne r
.
Ia
tro
ge ni
cMe chani
calPsy
chologi
cal • I nf
o r
mt hatsympt omsa r
eduet osidee f
fec
ts
Occl
usivevas
cula
rTraumaEx traf
act
ors ofanti-depressants.
Neurogeni
cChe mic
alEndo c
rine • Sy mpt omsa rer ever
sibleb ychangi
ngt he
doseo rthet y
peo fdrug.
I
nve
sti
gat
ions • Sub stit
ut ewitha nothera nti
-depre
s s
ant:
• CBC, bloodg l
ucos
e,TSH. Mi nima ltonos exualdy s
functi
on
• SeTe s
tost
erone. Ne fa
zodo ne(Se r
z one)
• Ur i
nal
ysis
. Bupr opion( We llbutri
n)
• Endo c
rinela
bt es
ts,
ifi
ndi
cat
ed: Lo wr i
sko fsexualdy sf
unction(10-15%)
FSH,LH, Prol
acti
n. Fl uvoxami ne(Luv ox)
Ci tal
opr a
m( Ce l
exa)
Ve nlafa
x i
ne( Effexor)
• Av oida lcohol/s
mo ki
ng .
• Me di
c altreat
me nt :
Ta bSi l
denafi
l25-5mg
PO 0.5t o4ho urspriortoc oit
us.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
&✓⌃ ⇥✓ ⌦
⌦ ⌦-=

Tayl
orJac
kson,a18yea
rsoldboypre
sent
edwit
hfe
v e
r,nec
ksti
ff
nes
sa ndpho
topho
biat
otheER.
Tak
ea
fo
cusedhi
sto
r yandpe
rfor
mf oc
usedphys
ica
lex
aminat
ion.
Vit
als
:BP-90/ 70mm Hg ,HR-110/ mi
n,RR-12/min,Temp–39.0°C.

Clini
calInfo:MrTayl
orJac
ksonhashighgradefe
v erfo
rthepas
t3da ysalongwi
thnecksti
ff
nes
s.Hehas
photophobiafort
hepas
t1da y
.Hea l
ert& cons
cious.Noseiz
ure
s.Ha sheadac
hewit
hna us
ea& vomi
ti
ng.No
eardis
charge.Hasapur
puri
crashonchestandlowerlimbs.Norece
nttrauma.Hash/ocont
actwi
thsi
ck
perso
nwi thsimil
ars
ymptoms.O/E:Febri
le
,Brudzinski
'sandKerni
g'ssi
gna r
epos
it
ive.
Clini
calCa se:Meni
ngi
tis

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha v
eme dicalil
lnesse
s?
• Ho wdidf eve rstart?Sudde norg ra
dua l
. • Ar eyo uona nyme di c
ations?
• Isitget
tingwo rse /
betterornoc hangesin • Ar eyo ual
lergictoa nyme dicat
ions?
t
hesympt oms ? • Anys urg
eri
e sinthepa st?
• Dur at
iono ffe ver? • Pa s th/orecurrentinfect
ions?
Conti
nuous /i
nt ermittent/
remit
te nt
?
• Dur at
iono fne c ksti
ffness
? Fa
mi l
yandSoc i
alHi st
ory
• As s
ocia
tedwi thhe adache/nausea/v
o mit
ing? • Doy ousmo k e
?Dur ati
on& f re
que ncy
.
• Anypho topho bia/phonopho bi
a? • Doy oucons umea lcohol?Dur at
ion&
• Anyf at
igue /
ma lais
e? frequency.
• Anyf ai
nting /seizures
/confusi
on/irr
itabi
li
ty? • Doy ouuser ecrea
tionaldrugs?TRAPPED.
• H/ ofeve
r /
co ug h/sorethroat
/ra
sh? • Anyf amil
yhi st
o r
yo fcanc e
rs/me dic
al
• Anyc hil
ls/nights we at
s? ill
ne s
ses?
• Anyc hestpa in/sho r
tnessofbreath?
• Anya bdo mina lpa i
n?
• Anyc hang esinbo wel& ur i
naryha bi
ts?
• Anyc ontactwi thas i
ckpe rs
on?
• Re ce
nttravel?
• Re ce
nthe adt rauma ?

Di
ff
ere
nti
alDiagnosi
s Ma
nage
ment
• Ba ct
eria
lMe ning
iti
s • Admi tunderi
sol
ation.
• Enc ephali
ti
s. • Startempir
icant
ibioti
cspri
ort
oLP.
• I nt
ra-c
erebra
labsc
ess. InjCefot
axi
me2gI Vq4h+
InjAmpicil
li
n50mg /kgIVq6h.
I
nve
sti
gat
ions InjDexamthasone10mgq6hI Vx4da
ys.
• CBC, ele
ctrol
ytes,
gluco
se. • Treatal
lclo
secontacts
.
• RFTs ,ABG.
• Lumba rpuncture-gramstai
n,micr
osc
opy,
c
ult
ure/
sensi
ti
v i
ty(r
uleoutpapi
ll
edema)
.
• Bl oodcultur
e/sens
it
ivi
ty,
gramstai
n.
• Ur i
nal
ysi
s.
• CTs canhe a
d.
• Che s
tXRa y
.
 - ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

J
a mesIr
wina30year
soldmanpr
ese
ntedtoyourc
li
nicwi
thsy
mptomsofhe
ada
che
.Ta
keaf
ocus
edhi
st
ory
andaddre
sshi
sconc
erns
.
Vita
ls:
BP-120/88mm Hg ,
HR-96/ min,RR-12/min,
Temp-37.
5°C.

Cli
nica
lInf
o:MrJ amesIrwinprese
ntedwit
hunila
ter
a l
,pul
sat
ingheada
che,gra
de7/10forthepast6
months.
Hee xpe
rie
ncesaurapri
ortotheonseto
fhe adache
.Assoc
iat
edwi t
hnausea
,vo
mi t
ingand
phot
ophobi
a.Sti
mulat
edb ystr
essandexc
ess
ivecaf
fei
neintake
.Oneepisodela
stsf
or8-12hours.
Heha d6
at
tac
ksinpast6mo nt
hs.Curre
ntlyonadvi
lprn.
Cli
nica
lCase:He a
dache(Mi g
raine)

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha v
edi abetesorhy pert
ension?
• Ho wdi di tstart?Sudde norg radua l. • Anyhe adtraumai nt hepa s
t?
• Lo ca
tio no fpa in? • Ar eyo uona nyme di c
ati
o ns?
• I sitget ti
ngwo r
s e
/bettero rnoc hang esin • Ar eyo ual
lergictoa nyme dicat
ions?
thesympt o ms ? • Anys urg
eri
e sinthepa st?
• Si nceho wl ongha veyo uno ticedt hepa in? • Pa s th/orecurrentinfect
ions?
• Numbe ro fep i
sodeso fhe adachet illno w?
• Ho wma nyho urspainl asts? Fa
mi l
yandSoc i
alHi st
ory
• Ho wdo e sthepa i
nf eellike? • Doy ousmo k e
?Dur ati
on& f re
que ncy
.
• Do esthepa inr adiat
eo rshoo tany whe re? • Doy oucons umea lcohol?Dur at
ion&
• Se verityo fpa ino nas ca l
eo f1- 10. frequency.
• Anypr ov okingf act
o r
sl ikefoo d,alcoho l
, • Doy ouuser ecrea
tionaldrugs?TRAPPED.
caff
eine ,cho colate,
wi ne ,s
tress. • Anyf amil
yhi st
o r
yo fcanc e
rs/me dic
al
• Ho wdo e sthepa i
nde crease? ill
ne s
ses?
• Doy o urs ympt omsc ha ngewi tht i
me ?
• H/ ofev er/coug h/sorethr oat
/na salstuffi
ness
?
• Anye x cessivelac r
ima t
io n?
• Anyv isua lcha ng e
spr iortoo ns eto f
headac he?
• Anyne c kpa in/rig
idity/sei
zure s?
• Anywe akne ss/
mus clepa in/paresthe s
ias?
• Anymo o dc hang es
/de creaseds l
eep/ energy
?

Di
ff
ere
nti
alDiag
nosi
s Ma
nage
me nt
• Mi g
rai
newithAur a. • Sy mpto matictrea
tme nt
.
• Te nsi
onHe adache. • Av oidtriggers.
• Cl ust
erHeadache. • Mi ldattack-ASA, I
buprof
en.
• Te mporalArte
riti
s • Mo derat
ea tt
a ck-Ant i
-emeti
cs,
Ibuprofen,Tr i
pta
ns,ergot
s.
I
nve
sti
gat
ions • Se ver
ea tt
ack-Ant i-
emetic
s,Ergot
amine
s,
• CBC, ESR Tri
ptans.
• Mi grainepr ophyl
axis–Propranol
ol,
Amy tr
iptil
ine,Verapamil
.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
&✓⌃ ⇥✓ ⌦
⌦ ⌦

MichaelSmit
h,a55year
soldmanpre
sente
dwithches
tdis
comf
ortf
orthepa
st1ho
ur.
Tak
eaf
ocus
ed
hi
st
o r
ya ndper
formfo
cusedphy
sic
ale
xaminat
ion.
Vi
tals
:BP-160/ 90mm Hg ,
HR-96/ min,RR-12/min,
Temp–37.5°
C.

Cli
nic
alInfo:MrMi c
haelSmithpre
sent
edwithle
ftsi
dedchestdi
scomf
ortfo
rt hepast1hour.
Hehaspai
n
i
nhislef
tsho ul
derandjaw.Hehasshort
nes
sofbreat
ha l
ongwithpal
pit
ati
ons
. Hei saknownhype
rte
nsi
ve
anddi
abeti
cso noralmedic
ati
ons.
Hi swi
festa
tesheisnon-c
omplia
ntwithhisme dic
ati
ons.
ECG showsST
el
eva
tio
ninl eadsII
,II
Ianda v
F.
Cli
nic
alCas e:ChestPain(Myocar
dialI
nfa
rct
ion)

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha v
edi abetesorhy pert
ension?
• Ho wdi dits tart?Sudde no rg ra
dua l
. • Ar eyo uona nyme di c
ati
o ns/
compl i
ance?
• Isitgett
ingwo rse/bett
ero rnoc hangesin • Ar eyo ual
lergictoa nyme dicat
ions?
t
hesympt oms ? • Anys urg
eri
e sinthepa st?
• Dur at
iono fc he stdiscomfo r
t? • Pa s th/orecurrentinfect
ions?
• Lo cat
iono fc he stdiscomfo r
t?
• Ho wdo est hedi s comfortfeelli
k e
? Fa
mi l
yandSoc i
alHi st
ory
• Anypa ina ssoc ia
t edwithc hestdiscomfor
t? • Doy ousmo k e
?Dur ati
on& f re
que ncy
.
• Do esthepa inr a
di at
eo rshoota nywhere? • Doy oucons umea lcohol?Dur at
ion&
• Se v
eri
tyo fpa ino nas c
a l
eo f1-10. frequency.
• Anys hortne sso fbr e
ath? • Doy ouuser ecrea
tionaldrugs?TRAPPED.
• Anypa lpitations/ dia
pho r
esis/
dizziness
? • Anyf amil
yhi st
o r
yo fcanc e
rs/me dic
al
• Doy ours ympt omsbe c
o mec hangewi th ill
ne s
ses?
t
ime??
• H/ ofever/coug h/ sor
ethro at
/ras
h?
• Anyhe mo pt ysis?
• Anyhe artbur n?
• Anya bdo mi na lpa i
n?
• Anywe akne sso rmy algia
?
• Anyc hang esi nbo wel& ur i
naryha bi
ts?
• Anys we l
li
ngo ffe e
t?
• Anyr eli
evingf actors?
• Anya ggrava ti
ngf actor
s?

Di
ff
ere
nti
alDiag nosi
s Ma
nage
me nt
• My oc
a rdialInf
arc
ti
on. • Admi ttoc ardiaccar
euni t
.
• Uns tableAng i
na. • Ur gentc ar
di ol
ogyc onsul
t.
• Pe ri
carditi
s. • Na salox y
g en.
• Pa ni
cAt ta
c k
. • Ta bAs pirin160- 325mgc hewabl
estat
.
• I njMo rphine2- 4mgI Vstat& prn.
I
nve
sti
gat
ions • Sub li
ng ualNi tr
o l
yce
rine0.4mgs tat
,re
peat
• CBC, e
lec
tro
lyt
es,
gluco
se. 3t imes.
• I NR/ PTT. • I njAt enolol5mgI Vbo l
usov e
r5mi ns,
the
n
• Se ria
lCK- MB& Tr oponi
nq8hX3. repeat.
• ABG. The ns witcht oo r
alAtenolol50mg .
• CXR. • Ca rdiacmo ni t
oringevery30mi nute
s-1
• 12l eadECG. ho ur.
• Be dre s
t.
• Co nsiderPCI ,incaseofno
cont r
aindications.
 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Adam Sawy
er,a18y
ear
soldmalepr
ese
ntedwithf
eve
r,c
oughfor1we
ekalongwi
ths
hor
tne
sso
fbr
eat
h.Ta
ke
afo
cusedhi
sto
ryandpe
rfo
rmf o
cuse
dphy s
ica
lexa
minat
ion.
Vit
al
s:BP-110/70mm Hg ,
HR–96/ min,RR–20/min,Temp–38.
5°C.

Cli
nica
lInfo:Adam Sawyerhasf
everandexpe
cto
rantco
ughfort
hepas
t1wee
k.Heha swhe
ezi
ngand
s
hortne
sso fbr
eathfor2days
.Ona usc
ult
ati
onofches
t,t
her
eisde
cre
ase
dbr
eat
hsoundsonle
fts
idewi
th
r
ale
spresent.
Cli
nica
lCa se:Pneumonia

HOPI Pa
stHis
tor
y
• OCD PQRSTUVW +AAA • Doy ouha v
edi a
bet
esorhy per
tensi
on?
• Ho wdi ditstart?Sudde norg radua l
. • Areyo uona nymedic
ati
ons ?
• Isitg ett
ingwo rse/bette
ro rnoc hangesin • Areyo ual
lergi
ctoanyme dica
tions
?
t
hes ympt oms ? • Anys urg
eri
e si
nthepast?
• Dur ationo fco ug h? • Pasth/orecurr
enti
nfect
ions?
• Ty peo fcoug h-dr yo rexpectorant?
• Isthe r
ea nyc he stpain? Fa
mi l
yandSoc ial
Hi st
ory
• Lo cati
o no fche stpain? • Doy o
us mok e
?Dur at
ion& f
requency
.
• Ty peo fpain–s ha r
po rdull? • Doy o
uc onsumea l
cohol
?Dur a
tio
n&
• Do est hepa inr adiat
eo rshoo tany where? fr
e quency
.
• Se ver
ityo fpa i
no nas cal
eo f1- 10. • Doy o
uus erecr
eati
onaldr
ugs?TRAPPED.
• Pa i
npr esentwi thde epbr eathing ? • Anyf amilyhist
oryofcanc
ers
/me dic
al
• Ons eto fsho rt
ne ssofbr eat
h? il
lness
e s
?
• Anyno i
sybr eathingpr es
ent?
• Anyc hil
ls/nights weats?
• Anyc hang esinbo wel& ur i
na ryha bi
ts?
• Anyc ontactwi thas ickpe r
so n?
• Re centtravel?

Di
ff
ere
nti
alDiag
nos i
s Ma
nage
me nt
• Co mmuni tyAcquir
edPne
umoni
a. • Out patienttre
atment.
• Ac uteexa
c e
rbat
ionofCOPD. • Ta bDo xy cy
cli
ne100mgPO bi dx7day
s.
• Ac utebronchi
ti
s. • Ta bAz ithromycin500mgPO OD x5da ys
.
• As thma. • Re standa dequatehydrat
ion.
• Sy mpto ma t
ictr
eatment.
I
nve
sti
gat
ions • I npat
ienttreat
me ntfor48-72hour
s.
• CBC. • Ta bLe vo f
loxa
cin750mgPO q24h.
• Sput um gra
ms t
ainwit
hcul
tur
e/s
ens
it
ivi
ty
. • Ta bAmo xici
ll
in1000mgPO qi d+
• El ect
roly
tes
. • Ta bCl arit
hromycin500mgPO bi d.
• Re na
lfunct
iont
ests
.
• Che s
tXRa y.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
&✓⌃ ⇥✓ ⌦
⌦ ⌦%

Hel
enSolazz
oisanICUnursewhohadaneedl
est
ic
kinjur
y30minut
esagowhi
ledr
awi
ngbl
oods
ampl
e
f
rom apa
tie
nt.Takeaf
ocus
edhis
tor
yandaddre
ssherc
oncerns
.
Vi
tal
s:BP-120/88mm Hg,HR-86/ mi
n,RR-12/min,Temp-37.
0°C.

Cli
nicalInfo:MsHe l
enSolazzohadanee dlesti
cki nj
uryint
heICU30mi nute
sago.
Shewa sdra
wingbl
ood
sa
mpl eatthatti
me.Shewaswe ari
ngglov
es .
Sheha snohighri
skbe
ha v
ior.Herimmunest
atusfo
r
HIV/ HCV/ HBs Agisnega
tiveasof1yearag o
.Patient'
simmunest
atusisunknownasofnow.
Pat
ient'
sresultc
omebackpositi
veforHIV.
Cli
nicalCa seDiag
nosi
s:Postexposur
eprophy l
axisforHIV.

HOPI Pa
stHistory
• Me cha nismo finjury. • Doy ouha v
eme dicalil
lnesse
s?
• Wa st henur sewe ari
ngg loves? • Ar eyo uona nyme di c
ations?
• We rea dequa teo ccupati
ona lprecautions • Ar eyo ual
lergictoa nyme dicat
ions?
t
a k
e n?( li
keg loves,ma sk.
) • Anys urg
eri
e sinthepa st?
• De pt ho fne edlepe netra
t ion? • Pa s th/orecurrentinfect
ions?
• Ty peo fne edle-ho ll
owo rs ol
id?
• Ne e dleg aug e? Fa
mi l
yandSoc i
alHi st
ory
• Wa sa nybl oo dpr ese
nto nt hetipo fne e
dle? • Doy ousmo k e
?Dur ati
on& f re
que ncy
.
• Anyc ontactwi thpa ti
ent'sbo dyfluids? • Doy oucons umea lcohol?Dur at
ion&
• St epst akena fterinjury? frequency.
• I mmunes tatuso fthenur se? • Doy ouuser ecrea
tionaldrugs?TRAPPED.
• Whe nwa sthel astimmunes tatusche cked? • Anyf amil
yhi st
o r
yo fcanc e
rs/me dic
al
• I mmuni zationf orHe patitisAa ndHe patit
is ill
ne s
ses?
B?
• Anyhi ghr iskbe haviorl
ik eunpr ote
c t
eds ex
?
• Anys i
mi larincidentint hepa st
?
• I sthei mmunes tatusofthepa t
ientk nown?
• Pa tient'sme dicalhi s
tory?

Inve
sti
gati
ons Ma
nage
me nt
ForHe a
lt
hcareprofe
ssi
onal
: • Re a s
suranc e.
• CBC, el
ectr
oly
tes. • Re f e
rt oInf e
c t
iousDi seasec l
inic
.
• RFTs ,LFTs . • Re porttoo ccupationalhea l
thde ptwithi
n72
• HI V,HCV, HBsAg. hours& e very2we ek l
y.
Forthepati
ent:
infor
mt hept. • Ce rt
ifytowo rker'
scompe nsatio
nbo ar
dfor
• CBC, el
ectr
oly
tes. fi
leclaim.
• HI V,HCV, HBsAg. • Adv iseabo utsafesexpr acti
ces.
• I ncas
eo fposi
ti
veHIV/ HCV/
HBs
Agdo • Av oi
dpr eg nancy/breastfeeding.
vi
rall
oads& CD 4c ounts
. • Re peatblo odwo rk6we eks,12we ek
s,6
mo nthsa nd12mo nths.
• Pa tientHI V+t hens tartthenur seonpost
exposurepr ophylaxisfor4we eks.
• Co unsela boutsidee f
fectso fme dic
ati
ons.
 > ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Ja
cobSandl
er
,a50y e
arsol
dmanpr
esente
dhemopt
ysi
sandri
ghts
ide
dcalfs
wel
li
ngforthepas
t2days
.He
hadkneer
epl
ace
me ntsur
ger
y1wee
ka go.
Takeaf
ocus
edhis
tor
yandper
formfo
cuse
de x
a mi
nati
on.
Vit
al
s:BP-140/80mm Hg ,HR-110/min,
RR-18/min,
Temp–37.5°
C.

Cli
nical
Info:MrJacobSandlerhadar
ightkneere
pla
cement1weekago
.Henowpres
ent
edwit
h2epis
ode
s
ofhemopty
s i
sandri
ghtcalfswel
li
ngwi
tht e
nderne
ss.
Heha snof
evero
rinf
ect
iono
fsur
gic
alwo
und.
Ho man'
ssi
g nispo
sit
ivewithECG showingS1Q3T3patt
ern.
Cli
nical
Cas e:Pul
mona r
yEmbol is
m

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha v
edi abetesorhy pert
ension?
• Ho wdi ditstart?Sudde no rgradua l
. • Ar eyo uona nyme di c
ati
o ns?
• Isitg et
tingwo rse/be t
tero rnoc hangesi
n • Ar eyo ual
lergictoa nyme dicat
ions?
t
hes ympt oms ? • Anys urg
eri
e sinthepa st?
• Dur ationo fblo odi ns putum? • Pa s th/orecurrentinfect
ions?
• Amo unt/c olo ro fbloo do fsput um?
• Ons eto fshortne sso fbr eat
h/c hestpain? Fa
mi l
yandSoc i
alHi st
ory
• Pre s
enta tresto rwi the xertio
n? • Doy ousmo k e
?Dur ati
on& f re
que ncy
.
• H/ oo rthopne a? • Doy oucons umea lcohol?Dur at
ion&
• H/ opa roxysma lno ct
ur naldys pnea? frequency.
• Dur ationo flegs we ll
ing ? • Doy ouuser ecrea
tionaldrugs?TRAPPED.
• Whe reisthel egs we ll
ingl ocated? • Anyf amil
yhi st
o r
yo fcanc e
rs/me dic
al
• Anyl egpa i
na sso ci
a t
edwi thswe l
li
ng? ill
ne s
ses?
• Ty peo fpa i
n-s ha r
po rdullpa in?
• Do esthepa i
nr adiateo rsho ota nywhere
?
• Se ver
ityo fpaino nas c al
eo f1- 10.
• Anypa indur ingr est?
• Anypa inint heni ghtt i
me ?
• Anys kindisco l
o rati
o no flegs/na i
lchanges
?
• Anys kinulcera ti
o no flegs?
• Anyf ev er/c
oug h/ cold?
• Anyhe ada c
he /dizzine ss?
• Anywe akness/mus clepa in?
• Anypr olongedi mmo bili
sation?
• Anypa in/dis
c ha rgefromt hewo und?
• Anypr e-opo ri ntra-opc ompl ica t
ions
?

Di
ff
ere
nti
alDiagnosi
s Ma
nage
me nt
• Pul monaryembo l
is
m. • Admi tinI ntensi
vec ar
eunit.
• De epVe i
nThr ombosi
s. • El evatehe a dendt o45de gree
.
• Pul monaryedemaduetoCHF • Na salo xygen.
• My oc
ardiali
nfa
rct
ion. • Gi v ec hewa bl
eASA160- 325mg
imme diate
ly.
I
nve
sti
gat
ions • Se cureI Va cc
e s
s,bolusIVLa si
x40mg .
• CBC, RFTs . • Ve nt olinifwhe ezesareheard.
• El ectr
olyt
es,glucos
e. • Sub l
ing ualnitrospray,i
fbloodpre
ssureis
• Se ria
lCK- MBa ndTr o
poni
nq8hX3. adequa te.
• Ar t
eri
albloodg as
es. • I njMo r
phine1mgI V.
• D- di
me r
,PT, PTT, INR,f
act
ora
ssa
y. • I njHe pari
n7500UI Vbo l
us,t
heninfuseat
• ECG, Echocardi
ogram. 1200U/ h,thenswi t
chtowa rf
ari
n.
• Che s
tXRa y. • Co ntinuea nticoagul
a t
ionfor3mo nths.
• PETSc ano rVQ scan.
• Do ppl
ero flowerli
mbs.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
&✓⌃ ⇥✓ ⌦
⌦ ⌦0

J
aspe
rPreudhomme,
a16year
sol
dboyaknowne
pil
ept
icpr
ese
nte
dtoyourc
li
nicf
ort
hef
ir
stt
ime
.Ta
kea
f
ocus
edhisto
ryanda
ddr
esshi
sco
nce
rns.
Vi
tal
s:BP-120/88mm Hg,HR-96/mi
n,RR-12/
min,Temp–37.
0°C.

Cli
nica
lInfo:MrJas
perPre
udho mmeisaknownepile
pti
cfort
hepas
t6y e
ars
.Heisonre
gul
arant
i-
epi
le
pti
csandisnon-c
ompli
a nt
.Hisl
asts
eiz
urewas2mo nthsa
go.
Her e
centl
yst
art
edco
nsuminga
lcoho
l
wit
hfri
ends.Hismai
nc o
ncernistog
etadri
ver'
sli
cense
.
Cli
nica
lCas e:
Sei
zuredi
sorder

HOPI Pa
stHistory
• Ag eo fo ns et. • Doy ouha v
edi abet
esorhy pe
rtensi
on?
• Pr e cipitant s:Slee pde privation,dr ugs, • Anys urg
eri
e sinthepast
?
alco hol, TVs cree n, emo tionalups et. • Pa s th/orecurre
ntinfec
tio
ns ?
• De s cri
bet y peo fs eiz ure s.
• Sa liv ati
o n, c y
ano s is,to ng uebiting , Fa
mi l
yandSoc i
alHi st
ory
inco ntine nc e,aut oma tisms ,mo t
o rv s. • Doy ousmo k e
?Dur at
ion& frequency
.
visua l
/g ust atory/o lfact ory. • Doy oucons umea l
cohol
?Dur a
tio
n&
• Fr e que nc y& dur atio no fseizures. frequency.
• Wha tbo dypa rtsa ffec teda ndi nwha torder? • Doy ouuser ecr
eati
onaldrugs?TRAPPED.
• Pr o mo nto rys i
g ns( pre senc eofa ura :i
mplies • Anyf amil
yhi st
oryofcancers
/me dic
al
foca latta ck ). ill
ne s
ses?
• Po st-ictals tate( de cre asei nlevelo f
cons cious ne ss,he ada c he ,sensory
phe no me na ,tong ues o rene ss
,limbpa ins,
To dd' spa r alys
is-he mi plegia),
• De g reeo fc ontro la chi eve dwi t
h
me di catio ns.
• Wa saCTs cando newhe nseizureswe r
efir
st
diag no sed?
• Numbe ra ndde sc riptio no frecents ei
zures
.
• Ar et he ydi fferentf rom pr eviouss eizure
s?
• I sthepa tientha vinga nyne ws ympt o msli
ke
hea da che ,v omiting ,ne wne uro l
o gical
defic i
ts?
• Si dee ffect sofa nt iepi leptics:drows iness,
poo rc o nc entratio n, po orpe r
forma ncein
scho o l
, atax ia
s,pe r iphe ralne uropa thy,ac
ne,
nys tagmus ,dysart hr i
a ,hy pertri
cho sis
,
g i
ng ivalhy pertro phy .

Di
agnos
is Ma
nage
me nt
• Se iz
ureDi
sor
der • Di s
cusscompl i
anceofme di
cati
ons.
• Re gula
rfoll
owup .
I
nve
sti
gat
ions • Av oidal
coholconsumpt ion/s
mo ki
ng.
• CBC, ele
c t
rol
yte
s. • Av oidrecr
eati
onaldr
ug s.
• Se r
um drugle
vels
. • I nformt othepati
entMi nis
tryof
• EEG. Transportat
ionregul
ati
o nsrequir
epati
entt
o
bes ei
zurefre
efor1y earo rmo r
e.
• No tif
yMi nis
tryofTranspo r
tati
onas
require
db ylaw.
 8 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Sa
manthaHo,a56yea
rsol
dwoma npre
sent
edtoyo
urc
lini
cwit
hsympto
mso
fhe
ada
chea
ndbl
urr
yvi
si
on.
Ta
keaf o
cus
edhi
sto
ryandaddr
esshe
rconcer
ns.
Vi
tal
s:BP-130/
88mm Hg ,HR-86/min,RR-12/mi
n,Temp-37.
5°C.

Clinic
alInfo:MsSamanthaHopr e
sente
dwi t
hunila
ter
al,
lef
ttempor
als
idepulsa
tingheadache,
grade7/
10
f
o rthepast2we e
ks.
Sheexper
ience
sheadachewhil
echewingandco
mbinghe rhai
r.Associ
atedwit
hblurr
ing
ofvisi
onanddi pl
opi
a.Oneepi
sodelas
tsfor30minute
s.Curr
entl
yonadvi
lprn,at
enolol50mgOD a nd
multiv
ita
mi ns.
Clinic
alCa se:Te
mporalArt
eri
tis

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha v
edi abetesorhy pert
ension?
• Ho wdi dits tart?Sudde no rg radua l. • Anyhe adtraumai nt hepa s
t?
• Lo cat
io no fpa in? • Ar eyo uona nyme di c
ati
o ns?
• Isitgettingwo rs e
/bettero rnoc hang esin • Ar eyo ual
lergictoa nyme dicat
ions?
t
hesympt oms ? • Anys urg
eri
e sinthepa st?
• Sinceho wl ongha veyouno ticedt hepa in? • Pa s th/orecurrentinfect
ions?
• Numbe ro fe p i
sodeso fhe adachet illno w?
• Fo rhowl o ngt hepa inla s
ts? Fa
mi l
yandSoc i
alHi st
ory
• Ho wdo est hepa i
nf ee
llike ? • Doy ousmo k e
?Dur ati
on& f re
que ncy
.
• Do esthepa inr adiat
eo rs hoo tany whe re? • Doy oucons umea lcohol?Dur at
ion&
• Se ve
rityo fpa ino nas caleo f1- 10. frequency.
• Anypr ovo kingf act
o r
slikef oo d,alcoho l
, • Doy ouuser ecrea
tionaldrugs?TRAPPED.
c
affe
ine ,cho colate,
stress,combi ngha ir
. • Anyf amil
yhi st
o r
yo fcanc e
rs/me dic
al
• Ho wdo est hepa i
nde crease? ill
ne s
ses?
• Doy ours ympt o msc hang ewi tht i
me ?
• H/ ofev er/coug h/sorethro at
/na salstuffi
ness
?
• Anye x cessi
v elac r
ima t
ion?
• Anyv isua lcha ng e
swi thhe ada che?
• Anyne ckpa in/rig
idity/
seizure s?
• Anywe akne ss/
mus clepa i
n/ paresthe s
ias?
• Anymo odc hang es
/decrea seds l
eep/ energy
?

Di
ff
ere
nti
alDia
gnosis Ma
nage
me nt
• Te mporala
rte
rit
is
. • Hi g hdo seco rt
icost
e r
oids.
• Mi g
rai
ne. • Ta bPr edniso ne60mgPO OD unt il
• TI A. sympt omss ub s
idea ndESRi sno r
mal,t
hen
40mgPO OD f or4-6we eks.
The nta
perto
I
nve
sti
gat
ions 5-10mgPO OD f or2y ea
rs.
• CBC, ESR, CRP,LFTs. • Re la pse
so c
c urin50%i ftr
eatmentis
• Te mporalart
erybi
ops
y. stoppedbe fore2y ears.
• Vi s
ualacuit
y. • Mo nit
orESRr eg
ula r
ly
.
• Fundo sc
o py
. • I fvisuals ympt omspr esent
,thenadmit&
sta
r tInj Prednisolone1000mgI Vq12hf o
r
5da y s
.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
&✓⌃ ⇥✓ ⌦
⌦ ⌦'

Ja
sonScot
t,a30yea
rso
ldma npr
ese
ntedwithy
ell
owi
shdisc
olora
tio
nofey
esa
nds
kinf
ort
hepa
st1we
ek.
Takeafo
cusedhi
st
oryandper
for
mf oc
usedphy
sic
ale
xaminat
ion.
Vit
als
:BP-120/88mm Hg ,
HR-96/ min,RR-12/min,
Temp–38. 0°
C.

Clini
calInfo:MrJ as
onSc o
ttpr
esentedwithyel
lowis
hdiscol
ora
tio
no feye
sandski
nforthepast1we e
k.It
hasprogr
e s
sedg r
aduall
y.Hehasrightupperqua
drantabdomina
lpain.Hehaslo
ssofappet
it
e,mala
ise,
nauseaa
ndv omiti
ng.Hisuri
neishighcolore
dands t
oolispa
lecol
ored.Hehasl
owg r
adefeve
r.Heha sfe
w
ta
ttoosonhi sbodyalongwit
hbo dypier
cing.Heisachroni
calc
oholi
c,smoke
randIVdr uguse
rforthepast
10y e
ars
.
Clini
calCas e:Vira
lHe pat
it
is

HOPI Pa
stHis
tor
y
• OCD PQRSTUVW +AAA • Doy ouha v
eme dic
alil
lness
es?
• Ho wdi dits tart
?Sudde no rgradual
. • Areyo uona nyme dic
atio
ns?
• Isitget
t i
ngwo rse/betterornoc hangesi
n • Areyo ual
lergi
ct oanyme dic
ati
ons
?
t
hesympt oms ? • Anys urg
eri
e s/
dentalproc
eduresi
nthepa
st?
• Dur a
tiono fy ell
owi s
hdi s
colora
tion? • Pasth/orecurr
entinfect
ions?
• Anyf ever/
c hill
s/nights weats
?
• Anya bdo mi nalpain/locati
on/durati
on? Fa
mi l
yandSocialHist
ory
• Anyna usea/ vomi t
ing ? • Doy ousmo ke?Dur atio
n& f requency.
• Anypr urit
us /ras
h? • Doy ouconsumea l
cohol?Dur ati
on&
• Anybr uises/spontane ousbleeding? fre
quency
.
• Anyl os
so fa ppetite/weight? • Dous er ecr
eat
iona ldrugs?TRAPPED.
• Anybo we lc ompl ai
nt s
/colorofs t
ools
? • Anyt atto
o s
/bodypi erci
ng?
• Anyur inaryc ompl aints/c
olorofur i
ne? • Ar eyouinas exualrelat
ionship?
• Anyf at
igue /ma l
aise? • Doy oupract
ices a
fes ex
?
• Anyc onfusio n/i
rri
tability
/sei
zures? • Ar eyoua tri
sko fsexual
lytransmit
ted
• Anya gg r
ava ti
ngf actors? inf
ect
ions?
• Anyr el
ievingf actors? • Anyf amilyhistoryofme dicalil
lne
s s
es?
• Anyc ontactwi ths ic
kpe r
son? • I mmunizati
onhi story.
• Anyr ecentt rave
l?

Di
ff
ere
nti
alDiagnosis Ma
nage
ment
• Ac uteVi r
alHe pat
it
is
. • Sympt oma t
ictr
eat
me nt.
• Al cohol
iche pa
tit
is
. • Treattheprimarycause.
• Ba ct
e r
ialhepat
iti
s. • Educ at
ea bouts
afersexprac
ti
ces
.
• No t
ifypublicheal
thincaseofHAV,
I
nve
sti
gat
ions Hbs
Ag ,
HCVo rHI Vpo s
iti
vese
rol
ogy
.
• CBC, ele
ctr
oly
tes
,gluc
ose
.
• LFTs ,RFTs.
• I NR, PT,PTT.
• HAV, HBs Ag,HCV, HIVse
rol
ogy
.
• Ul t
ras
oundabdomen.
 9 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

AnnaLevy
,a32yea
rso
ldl
adypr
ese
nte
dwithl
owe
rabdomina
lpa
ina
ndv a
gina
lspo
tti
ngf
or2da
ys.
.Ta
kea
f
ocus
edhis
tor
y.
Vi
tal
s:BP-120/
80mm Hg.HR-90/min.
RR-12/min.
Temp-37.
5°C

Cl
ini
cal
Inf
o:MsAnnaLevypre
sent
edwithh/olo
we rabdo
mi na
lpai
nandvag
ina
lspot
ti
ngfor2da
ys.
LMP:
6wee
ksago
.Bi-ma
nualex
am ha
scerv
ica
lmo t
iontende
rnesswit
hopenosa
ndblee
ding+++.
Cl
ini
cal
Case:
Aborti
on

HOPI Obste
tri
calHistory
• OCD PQRSTUVW +AAA • Doy ouha vec hildre n?I fyes,t
hena skfor
• Ho wdi di tst a
rt?Sudde no rg r
adua l
. • Gr a v
idity
, Te rm/Pr ema turedeli
veri
es,
• I sitg ettingwo rse/bettero rnoc hangesin Abo rt
ions,
thesy mpt oms ? • Li ve/Mul tiplebirths , c
o mpl i
cat
ionsin
• Si nceho wl ongha vey ouno ti
cedt hepai
n? pregnancy.
• Whe reist hepa inl ocat
ed? • H/ oectopicpr eg na nc y?
• Sha r po rdul lpa in?
• Do est hepa inr adiat
eo rs hootany where? Pa
stHistor
y
• Se verityo fpa i
no nas caleo f1-10. • Doy ouha vedi abe teso rhy pert
ension?
• Ty pe& a mo unto fv agi
na lblee
di ng? • Ar ey ouo na nyme di cat
ions ?
• Numbe ro fpa dsc hang ed? • Ar ey oua l
le rgi
ct oa nyme dica
tions?
• Pa ssag eo fc l
o tspe rvagina ? • Anys urgerie sint hepa st?
• Doy ours ympt o msc hang ewi t
ht ime? • Pa sth/os ex uall
yt ra nsmi t
tedinfecti
o ns
?
• H/ ofe ver /
na use a/
vo miting?
• Anyc ha ng esinbo wel& ur i
naryha bi
ts? Fa
mi l
yandSoc i
a lHi story
• Da teo fla stme ns t
rua lperiod? • Doy ous mo keo rc o nsumea l
coho l
?
• La s
ti nter course? • Dous er ecrea t
iona ldr ug s
?
• Bl oo dg ro up? • Cur r
entlyinar elatio nship?Ho wl ong ?
• Se xualo r
ient ati
on?
Gynec
ologicalHi story • Ar ey oua tr is
ko fa b use?
• Ag eo fo ns etofme nse s • Anyf amilyhi s
tor yo fc ancers?
• Re gular/irregula r
?
• Dur ationo fme nses?
• Amo unto fbl eeding/pa s
s a
g eofc l
ots?
• Anydy sme no rrhea?

Di
ff
ere
nti
alDiagnosis Ma
nage
me nt
• Spo ntaneousabor
tio
n. • Admi t
.
• I nco
mpl eteabor
ti
on. • Di la
tat
ion& cur
ett
agei
nc aseofi
nco
mpl
et
e
• Ec topicpregna
ncy. abor
tion.
• I mplantati
onblee
d. • I VFforhe mo
dynamics
tabil
ity
.
• Po st
coitaltr
auma • Se ri
alBetaHCG ti
lll
eve
ls<1.

I
nve
sti
gat
ions
• CBC, el
ect
rol
ytes
,re
nalf
unc
ti
ont
est
s.
• Be t
aHCG
• Pe lvi
cul
tra
sound.
• Bl oodgr
oup& t y
pe.
⇥ ◆
⌦◆⇢
✓⇢⌦
,⌦"⇢
⇤✓⇤
⌅⇢⌦
:⌦⌘)⇥✓⇧
⇧⇡) ⌦
⌦ ⌦=

Rache
lOwens,a42yea
rsoldpri
migra
vidawhoi
s9weekspr
egnant
.Shec
amet
oyo
uro
ffi
cet
okno
wabo
ut
he
rg e
net
icr
is
ks.Tak
eaf o
cusedhis
tor
ya nda
ddr
esshe
rconc
erns
.

Cli
nicalInf
o:MsRa c helOwe nsconcei
vednatur
all
yandthisi
sherfir
stpr
egnanc
y.Sheissur
eofherdat
es.
Shedidn'
tha v
eanya ntenat
alvis
ityet.
Thisisherf
irs
tvi
sit
.Herho mepreg
nancytes
twa spos
it
ivet
wice
.No
fa
milyhisto
ryofgeneticdis
orders
.Sheisonlytaki
ngprenat
alvi
tamins.
Noh/ omedica
lill
nes
ses
.
Shedoesno ts
mokeo rc ons
umea lc
o hol
.
Cli
nicalCase:Ant
e na t
alVisi
t

HOPI Pa
stHistor
y
• Co ngra t
ula tet hepa ti
e nt. • Doy ouha vedi abe te
so rhy pert
ension?
• Whe nwa sy o urpe ri
o d? • Ar eyo uona nyme dica t
io ns?
• Co nceive dna t urall
yo rwi thtrea
tme nt? • Ar eyo uallergictoa nyme dicat
ions?
• Anya ntena talv isi
tstilldate? • Anys urgeri
e sint hepa st
?
• Anybl oodt estsa ndul tr
asounddo ne? • Pa sth/osex uallytransmi tte
dinfecti
o ns?
• Anyl o we ra bdo mi nalpa i
n? • Whe nwa sy o urlastPAPt e
st& results
?
• Anybl eedingpe rvagina ?
• Anyr adiatione xposuret il
lnow? Fa
mi l
yandSoc i
alHi stor y
• Anyme dica ti
o nt akeni nthepa st2mo nths
? • Doy ous mo keo rc ons umea lc
oho l
?
• Anyf e ver/na us ea/vo
mi t
ing? • Dous erecrea ti
ona ldrug s?
• Anyv agina ldi scharge? • Cur rentl
yi nar e l
ations hip?Ho wl ong ?
• I nt
akeo ff olica cidprio rtoc o
nce pti
on? • Ar eyo uatr is
ko fabus e?
• Bl oodg roup? • Anyf amilyhi st
o ryofc anc e
rs?
• Anyf amilyhi st
o ryofg ene t
icdis
o r
de rs
?
Gynec
ologi
calHi stor y • Anyh/ og ene ti
cdi sorde rsinthepa rt
ne r
s
• Ag eo fo nseto fme nse s famil
y?
• Re gular/ir
re gul ar? • Suppo r
tsyste ma tho me ?
• Dur ationo fme nses? • Anys tr
essorsa two rko rho me ?
• Amo unto fbl eeding/pa ssa
g eofclots
?
• Anydy sme no rrhea?

Obs
tet
ri
c a
lHi s
tory
• Doy ouhavechi
ldren?Ify
es,
thenas
kfor
• Gr avi
dity
,Term/Premat
uredel
iv
eri
es,
Aborti
ons,
• Li ve
/Mul t
ipl
ebirt
hs,co
mplic
ati
onsi
n
pre
gnancy.
• H/ oe c
topicpr
egnancy?
•

I
nve
sti
gat
ions Ma
nage
ment
• CBC • Gi veante natalbro
c hure
s.
• Ur i
necult
ure/s
ensi
ti
vi
ty,
micr
oscopy. • Di s
cussa bo utgeneticsc
reening&
• Be t
aHCG Counseling .
• ABO Rh, type. • Re f
e r
raltoa no bstetr
ici
an.
• Bl oodsugar,
TSH. • Nut ri
ti
o n& e xer
ciseinpre
g nanc y
.
• Me asl
es,
Mumps ,
Rubel
la
,Va
ric
ell
a,VDRL. • Av oidalco hol/s
mo king/
ter
a t
o genic
• HI V,HBsAg ,
HCV. medica
tio ns.
• Pe lvi
cult
rasound. • Di s
cussa bo utris
ko fDo wn's/Turner'
s&
ot
herge ne ti
cdisordersi
nelde rl
y
pr
imigrav i
da .
 - ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Li
saRaymond,a28ye
arsol
dla
dypres
ent
edtotheERwithl
owerabdomina
lpainont
hel
efts
idef
ort
he
pa
st12hour
s.
.Takeafoc
use
dhist
orya
ndperf
orm af
ocus
edexa
minati
on(Page63)
.
Vi
tal
s:BP-100/70mm Hg.HR-98/min.RR-16/min.
Temp-37.5°C

Cli
nica
lInf
o:MsLi
saRa y
,pres
entedwit
hh/ol
eftsi
delo
we ra
bdomi
nalpai
nfor12hourswi
thmi l
d
s
pott
ing.LMP:2monthsago
.Bi -
ma nua
lex
am hasce
rvi
calmoti
ont
ender
ness& l
efta
dnexa
lful
lnes
s.
Cli
nica
lCase:
Ect
opicPre
gnancy

HOPI Obste
tri
calHistory
• OCD PQRSTUVW +AAA • Doy o uha vec hi
ldr en?I fyes,t
hena skfor
• Ho wdi di tst art?Sudde no rg r
adua l
. • Gr a v
idity
, Te rm/ Pre ma turedeli
veri
e s
,
• I sitg ettingwo r se
/bettero rnoc hang e
sin Abo rt
ions,
thesy mpt oms ? • Li ve/Mul tiplebi rths, c
o mpl i
cat
ionsin
• Si nceho wl ongha vey ouno ti
cedt hepa i
n? pregnancy.
• Whe rei sthepa inlo cat
ed? • H/ oectopicpr egna nc y?
• Sha r po rdul lpa i
n?
• Do est hepa inr adiat
eo rs hootany whe r
e? PastHistor
y
• Se verityo fpa ino nas caleo f1-10. • Doy o uha vedi a
be teso rhy pert
ension?
• Ty pe& a mo unto fble e
di ngperv agina? • Ar ey ouo na nyme di cat
ions ?
• Doy ours ympt o msc hang ewi t
ht i
me ? • Ar ey oua l
le rgict oa nyme dica
tions?
• H/ ofe ver /nause a/v
o miting? • Anys urgerie sint hepa st?
• Anyc ha ng esinbo wel& ur i
naryha bit
s? • Pa sth/os ex uallytra nsmi t
tedinfecti
o ns
?
• Da teo fla stme nstr
ua lper i
od? • Whe nwa sy o urla stPAPt est& results
?
• Anyt ra umar ecentl
y ?
• Whe nwa syo url a
stme al
? Fa
mi l
yandSoc ialHi stor y
• Bl oo dg ro up. • Doy o usmo keo rco nsumea l
coho l
?
• Dous er ecrea tio
na ldr ug s
?
Gynec
ologicalHi story • Cur r
entlyinar elationship?Ho wl ong ?
• Ag eo fo ns eto fme nse s • Se xualo r
ient ation?
• Re gular/irregula r? • Ar ey oua tr is
ko fa buse?
• Dur ationo fme nses? • Anyf amilyhi storyo fc ancers?
• Amo unto fbl eeding/pa s
s ageofc l
ots?
• Anydy sme no rrhea?

Di
ff
ere
nti
alDiag nosi
s Ma
nagement
• Ec topicpregnanc
y. • Admi t
• Thr eatenedabort
ion. • I VF
• Pe lv
icInf l
amma t
oryDis
eas
e. • Ur g e
ntgy necol
ogyconsult
• Ov a
riant or
si
on. • Rho gami fneeded.
• Endo me tr
ios
is
. Me
dic
altr
eatment:
• I njMe thotre
xate50mg /m2g i
venIMa ss
tat
I
nve
sti
gat
ions dose.
• CBC. • Se ria
lBe t
aHCG t i
lll
evelsdropt
o<1.
• Bl oodg r
oup,typeandc
ros
smatc
h. • Co ntr
acepti
ona dvi
ceti
llcomplet
iono
f
• Be t
aHCG tre
atment.
• El ectr
oly
tes,
Re nalf
unc
ti
onte
sts
. • Sur gica
ltreatment:Laparosc
opy/
• Pe lvi
cultr
asound. Laparotomy .
⇥ ◆
⌦◆⇢
✓⇢⌦
,⌦"⇢
⇤✓⇤
⌅⇢⌦
:⌦⌘)⇥✓⇧
⇧⇡) ⌦
⌦ ⌦

Cat
hyDa v
ies
,a32year
soldl
adypr
ese
nte
dwithi
nabi
li
tyt
oconc
eiv
ef o
rthepa
st3y
ear
s.Ta
keaf
ocus
ed
hi
st
oryandaddr
esshe
rconce
rns
.
Vi
tal
s:BP-120/80mm Hg .
HR-88/ mi
n.RR-12/mi
n.Temp-37.0°
C

Cli
nic
alInfo:MsCa thyDa vi
eshasbeenuna bletoconce
iveforthepas
t3year
swithunprot
ecte
dinter
cour
se.
Shehasnottakenanytrea
tme ntsofar
.He rperi
odsa r
eir
regul
arwithprol
ong
edinter
val
s.Shehasweight
gai
nforpas
t2y ear
sandhi rs
utis
m. Sheisinamo nogamousrel
at
ionshi
p.Noothe
rstr
ess
ors.Shehasa5year
s
ol
ddaughterconce
ivednatura
lly.
Noo therme dic
a li
ll
nes
ses.
Cli
nic
alCas e:
Infert
ili
ty

HOPI Gynecol
og i
cal Hi stor y
• Si nceho wl o ngt ryingt oc onceive? • La stme nst rua lpe riod?
• Fr equencyo fs exua li ntercour se
? • Ag eo fo nse to fme nses
• Awa re
ne sso fov ulatio npe riod? • Re gul ar/ir
re gul ar?
• Anydi ffi
cul ty/pa i
ndur ing /afterint e
rcours
e? • Dur ationo fme ns es?
• Anybl eedinga fte rint er
c ourse ? • Amo unto fbl eedi ng/pass
ageo fclots
?
• Anywe ightg a i
nr ec entl
y ? • Anydy sme no rrhe a?
• Anye xcessiveha irg r owth?
• Anyv ag i
na ldi s
c ha rg e/t
y pe/dura t
io n? Obste
tri
c a
l
• Anya bdo mi na lpa in/ backpa in? • Doy o uha vec hildren?Ify e
s,t
he na s
kfor
• Anys we l
ling /ma ssesno tic e
di nt hebo dy? • Gr avidi t
y ,Te rm/ Pr ema t
uredeliveri
es,
• Anyhe a t
/co ldi nt oleranc e? Abo rtions,
• Anyni ppledi scha rg e/ty
pe /dur ati
o n? • Li ve/Mul tiplebi rths, c
ompl i
cationsi
n
• H/ orepetitivei nfe ctions? pre
g na ncy.
• H/ ofever/na use a/vo mi t
ing ?
Pa
stHi s
tory
Mal
ePar
tnerHi stor y: • Doy o uha vedi abe te
s/hypert
ens i
on/t
hyroi
d
• Anydi ffi
cul tydur ingi nte rc
o urse? di
seas es?
• H/ oprema t
ur ee jac ulati
o n? • Ar ey o uo na nyme dicat
ions?
• H/ odiffi
cul tyma int aininge jaculation? • Ar ey o ua l
le rgict oa nyme dicat
ions?
• Anya bdo mi na ls urg erie
s ? • Anys urgerie sint hepa s
t?
• Anyt r
a umat ot hepe lvi
ca r
e aint hepa st
? • Pa sth/ os ex uallyt ransmitte
dinf ect
ions
?
• Anyme dica lill
ne sses? • Whe nwa sy o url astPAPt e
st& r es
ults
?
• H/ omumpsi nc hi l
dho od?
• Ar ey ouo na nyme di cat
io ns/all
erg i
e s
? Fa
mi l
yandSoc i
al Hi stor y
• Doy ous mo keo rc o nsumea l
coho l? • Doy o us mo keo rc onsumea lc
o hol?
• Dous er ecrea t
io na ldr ugs ? • Dous ere crea tiona ldrugs?
• H/ osexua l
lyt rans mi tt
edi nfe ct
ions ? • Ar ey o ua tr is
ko fa buse?
• Anys t
re s
s orsa tho meo rwo rk ? • Anyf a mi l
yhi stor yofc a
nc e
rs?
• H/ oo fco nc eptio ni npa s trelat
ions hips?

Di
agnos
is • Hyst
ero
-sal
phing
ogr
am.
• Se co
nda
ryi
nfe
rti
li
ty
. • Lapa
ros
copy.
• Se
me nanal
ysi
s
I
nve
sti
gat
ions
• CBC, FBS,TSH. Ma
nage
ment
• Da y3FSH, LH,PRL±DHEAS, Free • Co mple t
ephysic
alexaminati
onofbot
hthe
t
est
ost
erone. pa
rtner
s .
• Da y21-23Proges
ter
one. • Treatthec a
use.
• Ba s
albodytempera
tur
emo ni
tor
ing
. • Suppo rti
vecounsel
ing.
• Pe lvi
cultr
asound • Timi ngo ft
heinter
c o
urseinrel
at
iont
o
ov
ulati
on.
• Re f
erraltoi
nfert
il
ityspe
c i
al
ist
.
 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Alys
saJo
ne s
,a18ye
arso
ldg
irlc
amet
oyouro
ffi
cer
eques
ti
ngf
orcontr
ace
pti
vepi
ll
s.Ta
keaf
ocus
edhi
st
ory
andaddr
essherc
once
rns
.
Vit
als
:BP-120/80mm Hg.HR-80/mi
n.RR-12/min.
Temp-37.0°
C

Cli
nic
al Inf
o:MsAl yssaJonesisa18year
so l
ds t
udentwit
hnosigni
fi
canthi
st
oryofmedi
cali
ll
nes
ses
.Shei
s
anact
ivesexualr
ela
tionshi
pfort hepa
st4mo nths.
Ha doneepi
sodeofSTI6mo nt
hsag
o .
LMPwa s1week
ago
.Nof amilyhis
toryofcancers.Cur
rent
lyusi
ngba r
ri
ercont
rac
epti
on.
Cli
nic
al Case:OCPCouns e
ling

HOPI Gy
nec
olog
icalHi s
tory
• Whe nwa st hel as tme nstrualperio
d? • Ag eo fonsetofme nses
• Doy oug ethe a dac heso f
ten? • Re gular
/ir
re g
ular
?
• Doy ouha vea nybl eedingdi sor
de r
s? • Dur ationo fmenses?
• Anyt hr ombo embo li
ce vents? • Amo unto fblee
ding/pa
ssa
geo
fcl
ots
?
• Anyl iverdi s
e ase? • Anydy sme norr
hea?
• Anyunc ont r
o lledhi ghbl oo dpress
ure? • Cur rentcontrace
ptio
nus e
?
• Anyhe artdis ease?
• Anyma s
si nt hebr east? Obs
tet
ri
c al
Hi s
tory
• Anya b norma lv aginalbleeding? • Ha v
ey oubeenpregnantbef
ore?
• Anyhi storyo fs exuallytransmitt
e d Ifyes
,thenaskforGr av
idi
ty,
i
nfect
ions? Term/Prematur
ede li
ver
ies
,Abort
ions
,
• Anya b norma lPAPr esul
ts? Live/
Mul t
ipl
ebirths,c
omplic
ati
onsin
• Whe nwa st hel as tPAPdo ne? preg
nancy.
• Sex ua
lo ri
e ntation? • H/ oe ct
opicpre
gna ncy?
• Cur re
nt l
yi nar elationship?Ho wl ong?
• Numbe ro fse xua lpa r
tners? Pa
stHis
tor
y
• Dopr act
ices af ese x? • Anyhospi
tal
iza
tio
ns?
• Doy ousmo keo rc onsumea lc
oho l
? • Anysur
g e
rie
sinthepas
t?
• Dous erecrea tiona ldrugs?
• Ar eyouo na nyme dicati
ons ? Fa
mi l
yHis
tor
y
• Ar eyoua ll
e r
g ict oa nyme dicat
ions? • Familyhi
st
oryo
fhype r
tens
ion/di
abet
es?
• Familyhi
st
oryofbr
east
/ovar
ian/e
ndometri
al
c
ance
rs?
• Familyhi
st
oryo
fbleedi
ngdisorder
s?

Inv
est
igat
ions Manage
me nt
• PAt est& compl e
tephy si
cal. • Ta bYa sminonet abOD f or28da y s
.
• Va gi
nal& Ce r
vicalswabs,cult
ure
/sens
it
ivi
ty
. • Ty picalst
art(s
tartatfi
rstSunda yafter
Me nses)
Benef
it
sofOCP • Be ginpillonfir
stSunda yafteronsetof
• Pr eventionofunwa ntedpregnanc
y . Me nses
• Re ducedblo
o dloss. • I fMe nsesst
artonSunda y,thens t
artpil
l
• De cre
aseddysme norrhea. Day1
• Cy cl
ere g
ula
rizati
on. • Us eba rr
ierContracept
ionfo rDa ys1-7
• De cre
asedri
sko fbr e
ast/
ovari
an/endomet
ria
lIfpi
lls
tart
eda ft
erDa y5:
cancers
. • OCPma ynotsuppressOv ulati
onf orfi
rst
• De cre
asedacne. cycl
e
• De cre
asedosteoporosis
. • Us eba rr
ierContracept
ionfo rfi
rstmo nth.
• De cre
asedPMSs ympt oms. • Fo ll
owup6we eksafte
rthes tar
to fthepil
l.
• Re ver
sibl
econtracepti
on.
⇥ ◆
⌦◆⇢
✓⇢⌦
,⌦"⇢
⇤✓⇤
⌅⇢⌦
:⌦⌘)⇥✓⇧
⇧⇡) ⌦
⌦ ⌦%

Mari
aSantos
a,a28yea
rsol
dladypre
sent
edwit
hlowerabdomina
lpa
in,dy
spa
reuni
aandv
agi
naldi
scha
rge
f
or1we e
k.Takeafo
cuse
dhis
toryandper
formf
ocuse
de xami
nati
on(
Page63)
.
Vi
tal
s:BP-120/80mm Hg.HR-90/ min.RR-12/min.Temp-38.
5°C

Cli
nic
alInfo:MsMa riaSantos
apres
ente
dwi t
hh/ ol
o werabdo
minalpai
nfor1weekwithdyspar
euniaand
f
oulsmell
ingvaginaldischar
ge.
Shehasmi l
dfev
erfor2da y
s.H/ounprot
ect
edint
erco
urse+.
H/ oofpa s
t
i
nfec
ti
on3mo nthsa g
o. LMP: 1weekago.Bi-
ma nualex
am hasce
rvic
almoti
ontender
ness& ri
ghtadnexa
l
f
ull
ness
.
Cli
nic
alCa se:
Pe lv
icInf l
ammator
yDi s
ease

HOPI Obste
tri
calHi story
• OCD PQRSTUVW +AAA • Doy o uha vec hi
ldr en?I fyes,t
hena skfor
• Ho wdi di tst a
rt?Sudde norg r
adua l
. • Gr avidity
, Te rm/ Pre ma turedeli
veries
,
• I sitg ettingwo rse/be tt
ero rnoc hangesin Abo rt
ions,
thesy mpt oms ? • Li ve /Mul tiplebi rths, c
o mpl i
cat
ionsin
• Si nceho wl ongha vey ouno ti
cedt hepain? preg nancy.
• Whe reist hepa inlo cated? • H/ oe ctopicpr egna nc y?
• Sha r po rdul lpa in?
• Do est hepa inr adiateo rshootany where? PastHistory
• Se verityo fpa i
no nas cal
eo f1-10. • Doy o uha vedi a
be teso rhy pert
ension?
• H/ opa inf ulinte r
co urse? • Di dy ous uffe rfroma nydi sease
si nthepas
t
• Ty pe& a mo unto fv aginaldisc
ha r
g e? lik
et ube r
c ulo sis
?
• Doy ours ympt o msc ha ngewi t
ht i
me ? • Ar ey ouo na nyme di cat
ions ?
• H/ ofe ver /
c ough/ rash/vomi t
ing? • Ar ey oua l
le rgict oa nyme dica
tions?
• Anyc hills/nights we ats? • Anys urgerie sint hepa st?
• Anyc ha ng esinbo we l& ur i
naryha bi
ts? • Pa sth/ os ex uallytra nsmi t
tedinfecti
o ns
?
• Anys po tti
ngpe rv agina ? • Whe nwa sy o urla stPAPt est& results
?
• Da teo fla stme ns t
rua lpe r
iod?
• Doy oupr actices af
es e
x ? Fa
mi l
yandSoc ialHi stor y
• Numbe ro fse xualpa rtners? • Doy o usmo keo rco nsumea l
coho l
?
• Dous er ecrea tio
na ldr ug s
?
Gynec
ologicalHi story • Cur rentlyinar elationship?Ho wl ong ?
• Ag eo fo ns etofme ns es • Se x ualo r
ient ation?
• Re gular/irregula r
? • Ar ey oua tr is
ko fa buse?
• Dur ationo fme nses? • Anyf amilyhi storyo fc ancers?
• Amo unto fbl eeding /passa
g eofc l
ots?
• Anydy sme no rrhea?I ntrauteri
nede v
ice
s?

Di
ff
ere
ntia
l Diagnosi
s Ma
nage
me nt
• Pe lvicInfl
amma tor
yDiseas
ecaus
edduet
o • I njCe f
tri
axone250mgI Mstatdos
ewit
h
s
exuall
ytransmit
tedinf
ect
ions
,IUDs. • Ta bDo xy
cycline100mgPO bi dx14da
ys.
• Ov aria
nc yst
. • Re po r
tabl
edi sease
.
• Endo me tr
ios
is. • Tr eatpart
ne r
s.
• Ov aria
nt or
sion. • Av oidintercoursetil
lco
mpl
eti
ono f
• Ac uteappendici
ti
s. tre
atment.
• Pr act
icesafesex.
I
nve
sti
gat
ions • Re testwithcer v
icalswa
bsa
fte
r4-6weeks
.
• CBC
• Va gi
nal& Cerv
ica
lswabs,
cul
tur
e/s
ens
it
ivi
ty
.
• Ur i
necul
ture
/sens
it
ivi
ty
.
• Be t
aHCG
• Pe lvi
cult
raso
und.
 > ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Jul
iaMa r
sha
ll
,a30y ea
rsol
dladypr
ese
ntedtot
heERwi thbri
ghtredvagi
nalbl
eedi
ngf
ort
hepa
st1ho
ur.
Sheis36weekspreg
nant.
Takeafoc
usedhis
tor
yaddr
essherconc
erns.
Vit
a l
s:BP-100/70mm Hg .HR-100/min.RR-14/min.Te
mp-37. 5°C

Cli
nica
lInfo:MsJul
iaMa r
shal
lisG2T1P0A0L1a t36weeksg
est
ati
on.Sheha
spainle
ssva
gina
lbl
eedi
ng
f
orthepast1hour
.Ha snocontr
act
ions
.Fe
talhe
artr
atei
s130/
minut
e.Shehasapre
vioushi
st
oryofc
esar
ean
s
ect
ion.
Cli
nica
lCa se:
Pla
c e
ntaPrevi
a

HOPI Gy
nec
olog
ical
Histor
y
• OCD PQRSTUVW +AAA • Re gul
ar/
ir
regul
arme
nse
s?
• Ho wdi di tstart?Sudde no rg ra
dua l
.
• I sitg ettingwo rse/betterornoc hang e
sin Obs
tet
ri
c a
lHistory
thesympt oms ? • Doy ouha vec hi
ldren?Ify es,thenaskfor
• Si nceho wl ongha vey ouno tic
edthe Grav
idi
t y
,Term/ Prema t
ur edeliv
eri
es,
bleeding ? Abort
ions,Live/
Mul tipl
ebi rths,
• Amo unto fbl eeding? compli
c a
tionsinpregna nc y
.
• Co l
o ro fbl eeding ? • H/ oectopicpregnancy?
• Numbe ro fpa dsc hang ed? • H/ oplacentaprevia
/a bruptioplacenta
e?
• Anypa ss ageo fc lot
s? • H/ oofc e
sareans e
ctio
na ndther ea
s o
n?
• Anyl e akingno ticedpe rv a
g ina? • Anys urgeri
eso ntheut erus?
• Anyt ra umar ec entl
y ?
• Ar ef etalmov eme ntsf e
lt? Pa
stHis
tor
y
• Anya bdo mina lpa i
n? • Doy o
uhavedia
bet
esorhyper
tensi
on?
• Anyf e ver /nausea /
vo miting? • Areyouo
na nymedic
ati
ons?
• Anyc ha ng esinbo wel& ur inaryha bit
s? • Areyoua
ll
ergi
ctoanymedica
tions
?
• Whe nwa sthel astintercourse?
• Da teo fla stme ns t
rua lperi
o d? Fa
mi l
yandSoci
alHist
ory
• Anyc ompl icat
io nsint hea ntenatalperi
od? • Doy ousmo keorcons
umealco
hol?
• Whe nwa sthel astant enat
a lvi
sit? • Dous erecr
eati
onaldr
ugs
?
• Anybl eedi nge pisodedur i
ngpr egna ncy
? • Ar eyo
ua tri
skofabus
e?
• Bl oo dg ro up? • Anyf amil
yhist
oryofmedi
cali
ll
nes
ses
?

Di
ff
ere
nti
alDiagnosi
s Ma
nage
me nt
• Pl ac
entaprev
ia. • Admi tintheho spital
.
• Va saprevi
a. • Le ftlat
eralde c
ubituspo s
it
ion.
• Abr upti
oplacent
ae. • El ect
ronicfetalhea r
tmo ni
t o
r ing.
• Bl oodyshow. • I VF.
• Ma te
rnalv i
talmo nitori
ng.
I
nve
sti
gat
ions • I njRho ga
m, ifnee ded.
• CBC, e
lec
trol
yte
s,r
ena
lfunct
ionte
sts
. • GA<37we e
k s-mi ldbleeding-a dmit&
• Fe talul
tra
sound. obser
v a
tion.
• Bl oodg r
oup,ty
peandcros
sma t
ch. • GA>36we e
k s-pr ofus
eblee dingwit
hfet
o-
ma t
ernalcompr omi s
e-Ur g e
ntCe s
are
an
sect
ion.
⇥ ◆
⌦◆⇢
✓⇢⌦
,⌦"⇢
⇤✓⇤
⌅⇢⌦
:⌦⌘)⇥✓⇧
⇧⇡) ⌦
⌦ ⌦0

Ela
ineAbraha
m,a32yea
rsol
dla
dypri
migra
vida,
at34weeksges
tat
ionpre
sent
edtotheERwit
hhe
ada
che
,
ab
do mina
lpai
nandbl
urr
ingo
fvi
sio
n.Tak
eaf oc
usedhi
sto
ryandaddres
sherconc
erns
.
Vit
als:
BP-150/100mm Hg.HR-90/min.
RR-14/ min.Temp-37.0°
C.FHR=148/ min.

Clinic
alInf
o:MsEl ai
neAbr aham ha sahi
storyofpre
g na
ncyinducedhyper
tens
ionsi
nce28weeks.He rBP
iscontr
oll
edbydiet
aryrest
ri
cti
onsa ndlows al
tinta
ke.Shehasepiga
str
icpai
n,bl
urri
ngandheadacheforthe
past4-6hours
.Shehasfacia
landank leedema++. Therear
enoc ont
rac
tions
.Fet
almovement
sa r
ef e
lt.
No
ble
e di
ng.Uri
nedipst
ickisposi
ti
vefo rprot
einuri
a.
Clinic
alCase:PreEclampsia

HOPI Gy
nec
olog
ical
Histor
y
• OCD PQRSTUVW +AAA • Re gul
ar/
ir
regul
ar?
• Ho wdi dits tart?Sudde no rg radual
.
• I sitgettingwo rse/bettero rnoc hangesin Obs
tet
ri
c al
Hi story
thesympt oms ? • Doy ouha vec hi
ldren?
• Si nceho wl ongha v ey ouno ti
c e
dt hepai
n? • I fyes,
the naskforGr avi
dit
y,
• Whe r
ei sthepa inlo cated? Term/Pr ematuredeliv
eri
es,
Abo r
tions
,
• Sha rpo rdul lpa in? Live/Mul t
ipl
ebi r
ths,compli
cat
ionsin
• Do esthepa inr a di
a t
eo rsho o tanywhere? pregnancy.
• Se verityo fpa ino nas ca l
eo f1- 10. • H/ oe ctopicpregnancy?
• Ons eto fhe ada che ? • La stantenatalvis
it
?
• Lo cat
io no fhe adache ?
• Ty peo fhe ada che ? Pa
stHis
tor
y
• Ons eto fblur ringo fv ision? • Doy o
uha v
ediabet
esorhyper
tensi
on?
• Doy ours ympt omsc hang ewi thtime? • Areyouonanyme dic
ati
ons?
• H/ ofev er/
c oug h/ r
a s
h/ vomi ting? • Areyoual
ler
gictoanymedica
tions
?
• Anyc ha ng esi nbo we l& ur ina r
yha bi
ts? • Anysurg
eri
esinthepast
?
• Anybl e edingpe rv agina ?
• Anys we lli
ngo fthebo dy ? Fa
mi l
yandSoci
alHist
ory
• Fe talmov eme nts? • Doy ousmo keorcons
umea l
cohol?
• Anyc o ntractio ns/leak ingpe rvagina? • Dous erecr
eati
onaldr
ugs?
• To t
alwe i
ghtg a i
ni nt hepr eg nanc y
? • Ar eyo
ua tri
skofabus
e?
• Anya nt ena t
a lc ompl i
c ationsl ikehighblood • Anyf amil
yhist
oryofhyper
tens
ion/di
abe
tes
?
press
ur e/diabe tes/se i
zur es?

Di
agnos
is Ma
nage
me nt
• Ge s
tat
iona
lhy
per
tens
ionwi
thPr
e- • Admi tint heho spit
al.
e
cla
mpsia. • El ect
ro nicFe t
almo nit
ori
ng.
• Be dre stinle f
tlater
aldec
ubit
uspo s
it
ion.
I
nve
sti
gat
ions • Ho ur
lyma t
ernalvit
alsi
gnswit
h
• CBC, e
lec
trol
y t
es,r
enalfunct
iontes
ts. int
ake/o utputcha r
ti
ng.
• Ur i
naly
sis
,24ho ururina
ryprotei
n,l
iver • I njMa g nesi
um s ul
phate4mgI Vbo l
usover
f
uncti
ontests
,uricaci
d,LDH,a l
bumin. 20mi n,then2- 4g /
hforma i
nte
nance.
• I NR, PTT, Fibri
nogen. • Mo nit
o rsignsfo rma g
nesi
um tox
ici
ty.
• No nstr
esstest,
Bio-physi
calpr
ofi
le. • I njLabe tolol20-50mgI Vq10 minute
sti
ll
• Fe talul
tra
sound. BP<140/ 90mmHg .
• De l
iv
e rtheba by.
⇠✏H⌦ $ ⇠✏⌦ ⇠⌦ 23;⌦
&◆⇤ ✓⌅
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3) ✓⌅⇤
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↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
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Michael
Wa l
tera18mont
hso l
dboybro
ughttoyouro
ffi
ceb
yhi
smo
the
rre
gar
dingpo
orwe
ightg
ain.
Tak
e
hi
st
o r
yfromthemothe
r& addre
sshi
sconc
erns.

Cli
nic
alInfo:Michael
'
smo therisco
ncer
nedf orpoorwei
ghtgainforhisa
ge& hei
ght.
Heha sno
f
ever
/nause
a /
vomiti
ng/c
ough. Noh/ore
curr
e ntinfe
cti
ons
.Nour inar
yorbowelc
omplai
nts
.Hei spi
ckyeat
er
whogetsdi
strac
tedwil
ee a
tingfood.Hi
sdietconsis
tsofe
xcess
ivejui
ce& mil
k.Nofamil
yst
resspre
sent
.
Cli
nic
alCa seDiagnos
is:
Failuretot
hri
veduet oinade
quatedi
etaryint
ake
.

HOPI • Ma te
rna lma l
nutriti
on.
• OCD PQRSTUVW AAA • Ma te
rna lexhaustiono rMa jorDe pres
sion.
• Dur atio no fpo orwe i
g htg ain? • Anys t
re ssathome ?
• Sudde no rg radua lde clinei nwe ig ht
? • Anys i
gnso fphysical
/psycho l
og i
cal
/fa
mi l
y
• Qua litya ndQua ntityo ffo od? abus e
?
• Whof eedst hec hi l
d? • Fa milyhi st
o r
yo fshorts t
ature/FTTi n
• Do est hec hi l
df eeds e l
f(e .g.spo on, cup)? sibli
ng s
.
• Ps ycho so ci
a levent saro undf ee dingt ime . • Anyde ve l
opme ntalde l
ay?
• I sthec hilddi s
trac tedo rno ts upe rvi
s ed?
• Ar et he refo odba t t
leso rf oodr e fusa
l? Bi
rt
hhis
tory
• Di scus sf oodpr epa ration( e.g.fo rmul atoo • Ge stati
o nalagea tbir
tha ndbi rthwe i
ght.
dil
ute ). • Mo deo fde l
ivery:ces
a re
an, i
nduc t
ion,
• Be ve rage s(e.g.Mi l
k ,j
ui ce ,wa ter,soda ). forcepso rva c
uum de liver
y.
• St oo lha bits(e.g.freque nc yandc onsiste
ncy). • Anyf et
a ldist
ress?Wa sme conium passedin
• Pi cahi sto r
y. utero?
• De ta il
e dnur s
ingo rbr eas tfeedi nghi story. • APGARs c
o r
ea tbirt
h, 1mi nute& 5
• I nf
re que ntbr ieffee ding s. mi nute?
• Cur rentwe ight& he ig ht? • Wa sresuscit
ati
o nrequired?
• Hi g he s
twe ight? • Whe nwa sbreastfeedingsta r
ted?
• Anyf ever/na usea/vo mi ting /
c oug h? • Co lorof1 s
tstool,whe nwa s1s tst
ool
• Anydi arrhe a/cons t
ipa tion? pa s
sed?
• Anyur ina ryc ompl aint s? • Co lorofur ine,whe nwa s1 sturinepass
ed?
• H/ or ecur r
enti nfec ti
o ns? • Anya ntenatal/
po stpartum c o
mpl ic
ati
ons .
• Ma te r
na ling esti
ono fa lco ho l
/di uret
ics . • Immuni z at
ionhistory.
• I nade qua temi lks uppl y. • De velopme ntalmi les
tones.
• I nade qua temi lkle tdo wn. • De tail
eddi etaryhistory.

Dif
fer
enti
alDi agnosis • Ka ryotype.
• Phy s
iologiccaus e-Famili
alshortstature. • Wr i
stXr ay.
• Or ganiccause-Cl eftpal
ate,Cho anala tr
esi
a,
GERD, Ce l
iacds , Giar
diasis
,Pr o
teinl os
ing Ma
nage
me nt
enter
o pathy,Mi lkpr ot
einalle
rgy,Live rds. • Co mpl etephy s
icalexaminati
on.
• Chr onicdiarrhea. • Re assureparents
.
• Hy perthyroi
di s
m, I mmuno defi
c i
ency. • He i
ght& we i
ghtme as
urement.
• Pr enatalcauses-Intrauteri
neinfecti
on, • He a
dc irc
umf erence.
ma te
rna lmalnut r
ition,
Fe t
alalcohol • As ses
sf eedingpro c
ess& pa r
ent-
chil
d
syndrome , i
nteracti
on.
• Chr omo soma ldisorders. • De termine& t reatunderlyi
ngetiol
ogy.
• I ns
tit
utenut ri
tionalther
apy.
I
nvest
iga
tions • Ea tinac o mfort
a bl
e,str
essfr
eeenvir
o nment
• CBC, ESR, electr
o lyt
es,RFTs ,LFTs . wit
hpo s
itiv
er e
inforcement.
• Bl oods ugar,
TSH, SeFe rri
tin,
Swe atc hlori
de. • Co nsumef oodfro ma l
lfourfoo
dg roups.
• Ur i
nalysis
-routinemi c
roscopy,
C/ S. • Ma i
nt a
indi et
aryintakediary
.
• St oolfo rfa
tc ontent ,
ova& pa r
a si
tes
.
• SeCa l
cium, Pho sphate,Albumi n.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
2✓⌃◆⇤
⌅⇢ ⌦
⌦ ⌦'

Benj
aminSmit
ha15mont
hsol
dboyhasbe
enbroug
httot
heERwi t
hfe
vera
nd2e
pis
ode
sofs
eiz
ure
s.Hei
s
st
abi
li
zedno
w.Tak
ehi
st
ory& a
ddr
esst
heconc
ernso
fanove
ranx
iousmot
her
.

Cli
nicalI
nfo:BenjaminSmi t
hwa shav
ingarunnynoseandhi
ghg ra
defev
erforthepast3days
.Hisfeve
rdid
notsubsi
dewithTy l
enol
.Heha d1stepis
odeoftoni
c-c
loni
csei
zure6hour
sa g
oa thome .
Thiswasthef
irs
t
oc
c ur
rence
.Heha dnoo thersymptoms.Nofamil
yhis
toryofs
eiz
ures.
Noc ompli
cati
onsduri
ngbirt
ho r
de
v el
opmentsofar.Immunizati
onisuptodate.
Nos i
gnsofchil
da buse
.
Diagnosi
s:Febri
lesei
zures
.

HOPI • Hist
oryo fprobl
emsduringthepre
gna
ncy
• OCD PQRSTUVW AAA andbirth.
• De scri
bes eiz
uredur ati
o n? • Devel
o pmentalhi
stor
y.
• wha tbo dypa r
tsa ffecteda ndinwha torde
r, • Chil
d'sme dica
lhis
tory
.
premo ni t
o rysigns ? • Immuni zat
ionhis
tory
.
• Po st-ictalstate(de c r
easei nl eve
lof • Famil
yhi st
oryofsei
zuredis
orde
r.
conscious ne s
s,he adache ,we akness)
. • Scr
eenf orsi
gnsofchil
da b
use.
• Pr eviouss e i
zure?
• Ev e ntsdur ingt hes eizur et i
me ?
• Ho wdi dt heseiz uresto p?
• Ons eto ffe ver
?Sudde no rgradual?
• Dur ationo ffever?
• Ty peo ffev er
-co ntinuo us, remit
tent,
int
e rmittent .
• Anyna use a/vomi ting?
• Anye ar/eyedi s
c ha rge
/r unnyno s
e?
• Anyr ash?
• Anyc oug h/soret hroat/di ffi
cult
yswallo
wing?
• Anydi ff
icul t
ybr eathing ?
• Anybo we lo rur i
na ryc ompl ai
nts
?
• Anys i
ckc ontacts?
• As ka bo utpr ecedi ngtra umao ril
lnessor
me dicationst aken?

Di
ff
ere
nti
alDiag
nos i
s Ma
nage
ment
• Fe bri
les
eizur
e. • Sympt o
ma t
ictr
eat
me nt.
• Me ni
ngit
is
. • Antipyr
eti
csforf
everprn.
• Enc ephal
it
is. • Ma i
ntainhydr
ati
on.
• Couns e
li
ng& reas
surancef
orpa r
ent
s.
I
nve
sti
gat
ions • Recurre
nce-rect
alorsubli
ngualLor
azepa
m.
• CBC, e l
ectr
oly
tes,
RFTs . • Treatunder
lyi
ngcauseoffeve
r.
• ABG, Bloodgluco
s e
.
• Ur i
nal
y si
s.
• Bl oodc ul
ture& sensi
ti
vi
ty
.
• LP- gr
ams tai
n,cul
ture& se
nsi
ti
vi
ty
.
 9 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Ni
ckChangi
sa15year
soldboybroug
htb
yhi
smo
the
rwi
thf
eve
randr
ashf
ort
hepa
st2da
ys.
Ta
kehi
st
ory& a
ddr
essherco
ncerns
.

Clinic
alInfo:
Ni c
kha shighfeverf
orthepa
st2days
.Hede v
elo
pedadif
fusera
shinthela
st24hourswhich
isspre
adi
ngf r
o m headtotrunk.
Hea l
sohascoug
h,sor
ethro
atandr
ednessofeye
s.Hehasnoal
teredle
v e
lof
consci
ousness
/ir
ri
tabil
it
y.Hei sa
ler
tandfee
dingwel
l.Hash/osi
ckc
onta
c t
swithsi
mila
rcompla
intsinthe
daycare.
Hi simmuni za
tio
ni suptodate
.
Dia g
nosis:Measles
.

HOPI • Immunizat
ionhis
toryti
lldat
e?
• OCD PQRSTUVW AAA • Anyrecur
renti
nfec
tions
?
• Ons e
to ffe ver-s uddeno rg radual? • Deve
lopmentmiles
tonesforage
?
• Dur a
tiono ffe ver? • Anysi
mi l
arsymptomsinthepast
?
• Ty peo ffev er-
c
ont i
nuo us,remi ttent,
intermittent?
• Hi ghestr eco rdedt empe ra
ture?
• Re li
evingf a ctorsforthef ever?
• Ons e
to fra sh?
• Ty peo frash?
• Lo cati
o no fr ash?
• Ra shbe comi ngbe tterorwo r
se?
• Anyv esi
c l
e sno t
icedwi t
ht her ash?
• Anys wellingi nt hebo dy ?
• Anye ar/eyedi sc
ha rge?
• Anye xcessivec r
ying/irr
itabil
ity?
• Anyc hang esi na lert
nesso fthec hil
d?
• Anyc oug h/s orethroat/runnyno se
?
• Anyna use a/vo miting/diff
icul
tys wall
owi
ng?
• Anyc hang esi nur inary/
bo welha bit
s?
• Fee di
ngwe llo rnot?
• Anys ei
zur es?
• Anyr ecents ickc ontacts?
• Anyt r
a v
e l?

Di
ff
ere
nti
alDiagnosi
s Ma
nage
ment
• Me a
sle
s. • Symptomati
ctre
atment
.
• Rube ll
a. • Ma i
nta
inadequat
ehydr
ati
on.
• Va ri
cel
lazost
er. • Rest
.
• Er yt
hemai nf
ecti
osum. • Anti
pyret
ic
sforfev
erpr
n.
• Educat
eparent
saboutc
ompli
cat
ions
.
I
nve
sti
gat
ions
• CBCwi t
hdi
ff
ere
nti
al
.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
2✓⌃◆⇤
⌅⇢ ⌦
⌦ ⌦=

Mari
eJone
sdeliv
ere
dababyAntho
ny36hoursol
dandnowthenewbo
rnhasj
aundi
ce,
let
har
gya
ndc
ryi
ng.
These
rum bi
li
rubi
nis220mmol(N <200)
.Tak
ehist
ory& a
ddr
esshe
rconc
erns
.

Cli
nic
alInfo:Anthonywa sbo rntoapri
mi gra
vidabyno rmalv
aginaldel
ivery
.Mo t
hernoti
cedyel
lowis
h
di
scol
ora
tionofhiseyesinthemo r
ning.
Sheha dnoa ntenat
alcomplica
tions.
Shehadprematur
eruptureof
membranespriort
oo nsetoflaborat38we ek
s.Shewa sputonantibio
tic
s. Herl
aborwas18hourslong.
The
l
aborwasinduced.Apg a
rwa s9/10.Babyisalit
tlel
et
ha r
g i
candno tfe
edingwe l
l.
Ha snofe
ver/
alt
ered
co
nsci
ousness.
Nos eizur
es.
Cli
nic
alCa seDiagnosis
:Ne onatalJ
aundiceduetoSepsis.

HOPI • APGARs co r
ea tbirt
h,1mi nute& 5
Mot
her
'sobstet
rica lhi st
o ry: minute?
• GTPAL • Wa sre
susci
tati
onr equir
e d?
• H/ one ona ta ljaundic einpa s
tpre gnancie
s. • Whe nwa sbreastfeedi
ngs t
arte
d?
• Ma t
ernalme dicalhis t
o rye sp.l
iv
e rdiseas
e. • Ist
heba byfeedingwe ll
?
• I ll
nessdur ingpr egnanc ye sp.dia
be tes, • Colorof1ststool,whenwa s1ststoo
l
rubell
a, t
o xo plasmo s
is,he rpes,CMV. pas
sed?
• Te ratoge nicme dicati
o nsdur ingpr egnancy
. • Colorofurine,whe nwa s1 s
turinepass
ed?
• Ra dia
tione x posur einpr eg nancy? • Anyv omiti
ng/regurgit
ation?
• Dr uga nda lcoho lusedur ingpr e
g nancy? • Decreas
edne onatalmus cletone?
• Anype tsi nt heho use? • Anyfever,i
rri
tabil
ity,l
et
ha rgy,
seiz
ure?
• Ma t
ernal& Pa ternalbl oodt ype. •
• Co mpl i
ca tionso fpre s
e ntpr egnanc y
. • Pas
tHi s
tory
-Ge statio na lhy pertensiono rdia bet
es, • Doyouha vedia
bet
esorhy per
tensi
on?
hype r
/ hy po t
hy roid,hy pe r
coagulatio
n. • Areyouona nymedic
ati
ons ?
• Anya nt ena ta l
/po stpartum c o mplicat
ions? • Areyouall
ergi
ctoanyme dica
tions
?
• Anysurger
iesi
nthepast?
Ne
wbo r
nhistory: • Pas
th/orecurr
enti
nfect
ions?
• Ge stat
ionalageatbir
th, •
• Mo deofde l
iv
ery:ces
area
n,induct
ion, • Famil
yandSoci
alHis
tor
y
fo
rcepsorvacuum deli
ver
y. • Soci
als
uppor
t.
• Dur a
tio
no fruptur
eo fmembranes(ROM)? • Anyfamil
yhi
sto
ryofmedic
ali
ll
nes
ses
?
• Wa sROM a rti
fici
alorpr
olonged?
• Anyf e
taldis
tres
s?Wasme co
nium pass
edi
n
ute
ro?

Di
ff
ere
nti
alDiagnosis Ma
nage
me nt
• Se psi
s. • Pr eventk e
rnic
terus.
• Br eas
tfeedingja
undic
e. • Tr eatunde r
lyi
ngc ause.
• He moly
sis. • Mo nitorneonatalvit
al
s.
• Phy si
ologicja
undic
e. • Ma i
nt ai
nhy dr
ation.
• I ni
tiatephotot
he rapy
.
I
nve
sti
gati
ons • Re assuranceforparents
.
• CBCwi thret
ics
,el
ect
rol
yte
s,RFTs.
• Sebi li
rubin(
conj
ugated& unconj
uga
ted)&
al
bumin.
• Bl oo dg r
oup(ma t
ernal
,pat
erna
l&
neonat
a l
).
• Co o mb'stes
t.
• Bl oo d& ur i
necult
ure.
• TSH, G6PD.
• Che stXRa y
,LP.
%- ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

SeanRadcl
if
fei
sa8yea
rsol
dboywho
sepa
rent
sha
vec
onc
erna
boutbe
dwe
tti
ng.
Tak
ehi
st
oryf
romt
he
fa
ther& a
ddres
shi
sco
ncer
ns.

Cli
nic
alInf
o: Seanhasbeenwe t
tinghisbedsi
ncelas
t3year
s.Heneve
rha dbladdercont
rol
.Hehasno
f
ever
/vomit
ing.Noh/ orecurr
entinf
ect
ions.Hewe t
sbed2-3ti
mesinthenight
. Nodaytimewett
ingpr
ese
nt.
Noencopar
esis.
Pa r
entshavenottake
na nytre
atmentsof
arandhav
etrie
dt o
ile
tt r
aini
nginpas
twithno
s
ucces
s.Nos t
res
sesathomeo rs
chool.
Cli
nic
alCaseDi agnosi
s:Primarynoct
urnalenure
sis
.

HOPI • Enuresisino thersibling s

?
• OCD PQRSTUVW AAA • Anys t
r ess
esa thomeo rschool?
• Ty peo fv oiding-I nvo l
unt aryo rintentio
nal. • Anyne wha bitsorre gressi
ont oo ldhabits
?
• Numbe ro ftime swe tsbe di nt henig ht? • Tri
alo ftoil
ett ra
iningi nt hepa st?
• Ha st hec hilde verbe endr y ?(
pr i
ma ryo r • Anyt r
e atmenti nthepa stforenur es
is
?
seco nda r y
)
• I sthe reda ytimeEnur esi
s ?
(co mplicated Bi
rt
hhis
tor
y
Enur esis) • Gestati
o nalagea tbirtha ndbi rthwe i
ght.
• We ttingpa ttern-da y±nighto rnighto nly
. • Mo deo fde l
ivery:cesa r
ean,induc ti
on,
• Anydy suria/pyuria/fouls me l
lingur ine? for
cepso rva c
uum de liver
y.
• I nvo lunt arypa ss
ageo fs toolint hes leep? • Anyf etaldist
ress?Wa sme conium passedin
• Func tiona lbladde rdiso r
de rsignsl i
k e ute
ro?
-Vo ids>7pe rda ywi thur genc y& i nsma l
l • APGARs c
o r
ea tbirth, 1mi nute& 5
vo lume s. minute?
-Wi thho ldsur i
neunt illastmi nute ,
we t
s • Wa sresuscit
ationre quired?
mo ret ha no nceni ghtly. • Whe nwa sbrea s
tfee dings t
art
e d?
• Ha se nur esi
so no nl yaf ewni g htspe rweek? • Coloro f1ststo ol
,whe nwa s1s tstool
• Vo idsl a rg
ev olume swhe ne nur e
siso ccur
s? pas
sed?
• Bo we lo rbladde rha bitcha ng esrecently. • Coloro furine,whe nwa s1 s
tur inepassed?
• I nfre que nto rdi ff
icults t
oo lpa ss
age? • Anya ntenatal/postpa rtum compl ica
tions.
• Anyc ha ng esina ppe t
ite/we ight? • Immuni z a
tionhi s
to ry.
• Anyf eve r
/na usea/vomi ti
ng ?
• Anyr ecurrenti nfections?
• Amo unto ffluidint akepr iortos leep?
• Anyne urolog i
c a
ldi sorders?
• Anyg eni t
o urinarys urgeries?

Di
ff
ere
ntia
lDiagnosis Ma
nage
me nt
• Pr imarynocturnalenure
sis
. • Co mpl etephy s
icalexaminati
on.
• Ur i
nar
ytractinfe
c t
ion. • Re assurepa r
ents.
• Ur i
nar
ytractanoma li
esli
kesma
llbl
adde
r. • Sc hedulev oi
dingt i
me s.
• Ps ychol
ogic
al( de
a t
hi nt
hefami
ly,
sex
ual • Be dwe tti
nga lar
m.
a
buse)
. • Vo idbe forebedti
me .
• Li mitfluids1ho urbeforebedti
me .
I
nve
sti
gat
ions • Vo idingdi ar
ytobema inta
ined.
• CBC, el
ect
rol
yte
s,RFTs,LFTs. • Po sit
ivereinfor
ceme ntfordrynight
s.
• Bl oodsugar
. • Pha rma cologi
caltherapyli
ke
• Ur i
nal
ysi
s-r
outi
nemicr
oscopy
,C/S. Imipramine /
DDAVP .
• Ul t
ras
oundabdomen.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
2✓⌃◆⇤
⌅⇢ ⌦
⌦ ⌦%

Al
lySi
nge
r'
s6we
ekso
ldba
bybo
yAl
exi
svo
mit
ingf
ort
hepa
st2da
ys.
Tak
ehi
st
ory& a
ddr
esshe
rco
nce
rns
.

Cli
nic
alInf
o:Alexhad4e pis
odesofproj
e c
ti
lenonbil
iousvomiti
nginthepast48ho ur
s.Hevo
mi t
saft
er
f
eedi
ng.Nofeve
r.Lo o
ksletha
rgi
c& de hydrat
edbutal
ert.Noseiz
ures
.Ha donlyonebowelmovementi
nlas
t
24hours
.Nosic
kc onta
cts
.O/ E:Pa
lpableabdominalmassintheri
ghthypoc
ho ndri
um.
Cli
nic
alCaseDiagnosi
s:Py l
ori
cst
enos i
s.

HOPI Mot
her
'sobstetri
calhistory
• OCD PQRSTUVW AAA • GTPAL
• Numbe ro fepisodeso fvomiti
ng? • Ma t
ernalme dicalhistoryesp
. l
iverdiseas
e.
• Dur a
tiono fvomi t
ing? • I ll
nessdur i
ngpr egnancyesp.diabet
es ,
• Typeo fvomi ti
ng-pr o j
ecti
le
/nonproj
ect
il
e? rubell
a, t
oxoplasmo s
is,
he r
pes,CMV.
• Color/co
nt entsofv omitus? • Te ratogenicme dic
a t
ionsduringpr e
g nancy
.
• Anye xcess
ivec ry
ing? • Ra dia
tionex posureinpr egnancy.
• Fe
e di
ngpa tt
erninl as
t48ho urs? • Dr uga ndalcoho lusedur i
ngpr egnancy.
• Decreasedne onatalmus cl
etone? • Co mpl i
cati
onso fpresentpre
g nancy.
• Anyf eve
r,irri
tabil
ity
,let
ha r
gy,
sei
zure
? -Ge stat
ionalhy pertensi
ono rdiabetes,
• Lastbowe lmov eme nt? -hype r
/hypo thyroid,hyper
co a
g ul
ation.
• Foulsme l
lingur i
ne& c o l
orofuri
ne? • Anya nt e
nata l
/po s
tpa r
tum co mplic
ations?
• Currentwe ight.
• Anys i
ckc ontacts.

Ne
wbornhi
story
• Gestat
ionalag ea tbir
tha ndbi r
thweight.
• Mo deofde l
ivery :caes
arean,induct
ion,
for
cepsorva cuum de li
very.
• Anyf e
taldistress?Wa sme conium pass
edin
ute
ro?
• APGARs c
o rea tbirt
h,1mi nute& 5
minute?
• Wa sre
suscit
a t
ionr equir
e d?
• Whe nwa sbr eastfeedi
ngs tarte
d?
• H/one onataljaundice.
• Colorof1sts tool,whenwa s1stst
ool
pas
sed?
• Colorofurine ,whe nwa s1sturinepass
ed?

Di
ff
ere
nti
alDiagnosis Ma
nage
me nt
• Py lo
r i
cstenos
is. • Admi t
.
• Tr ac
he o-es
ophagealf
ist
ula
. • Ur gentPedia
tri
csurg
erycons
ult
.
• Duo denalat
res
ia. • I VFtoma int
ainhydra
tio
n.
• Ma l
rotat
ionofgut. • Sur g
e r
y-Pylo
romyotomy.
• Ga stro-e
sophagealre
fl
ux.

I
nve
sti
gat
ions
• CBC, el
ectro
lyte
s,RFTs,
LFTs
.
• ABG.
• Ur i
nal
ysis
.
• Ul t
ras
ounda bdomen.
• Abdo minalXr a
y.
% ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

J
ohnAndr
ewsi
sa3y
ear
sol
dbo
ywhoi
sno
tspe
aki
ngwe
ll
.Ta
kehi
st
ory& a
ddr
esshi
sfa
the
r'
sco
nce
rns
.

Cli
nical
Info:Jo
hnAndr ewshash/ore
currentearinfe
cti
o ns.Hehad3e pisodesi
nthea l
st6months.Hehas
r
unnyno seandmildcoughtoo
.Hec anspeakins e
ntenceo f3-4words
.Hec ancountto5.Butfort
hepast3
monthsheisnotlea
rningnewwo r
dsornumbe rs
. Her e
spo ndstol
oudso unds.Noo t
hercompla
ints
.Soci
al
i
nter
acti
onisverygood.Nobir
tho rde
velopmentalcompl i
cati
onst
il
ldate .
Diagnos
is:Speec
hde l
aysec
ondarytore
cur r
entotiti
sme dia.

• Dur at
iono fs pee chde lay?
• Whono ticedi tf ir
st?
• Anye ardi scha rg e/runnyno se?
• Anyr ecur renti nfec ti
ons?
• Anyf eve r/coug h/ sorethroat
?
• Do e sthec hildwa k eupinr es
po nseto
sounds ?
• Startlet ol ouds ounds ?
• Co me swhe nc alled?
• Unde rs
t ands po k eni nstr
ucti
o ns?
• Aska bo uts wi mmi ng .
• Enqui reo fv erba lcue s
.
• Ho wma nyl ang uag esarespok e
ni nthe
hous eho ld?
• Chi ld'
ss o cialint eracti
onwi tho t
hers.
• Do e sthec hildt alkl es
sinpa rti
cular
si
tua ti
o ns?
• Ho wma nywo rdsa respokenb ythec hi
ld?
• De tail
e dde velopme ntalhist
or y
.
• Wa sthec hilds creene dforhea r
inga tbi
rth?
• Anyr egre ssi
o ni nha bi
ts?
• Immuni zationhi storytil
ldate.
• Fami l
yhi sto ryo fs peechde l
ay.
• Anyc ompl icationsdur i
ngpr egnancyo r
bi
r th?
• De tail
e dbi rthhi story.
• Ex po s
ur et ot oxinsdur i
ngpr egnancy?
• Anyo to toxicdr ug sus edininf a
ncy?
• Scre enf ors i
g nso fchildabuse.

Di
ff
ere
nti
alDiagnosis Ma
nage
ment
• He a
ringlos
sseconda
rytoOt
it
isme
dia
. • Reas
sura
ncef o
rpa r
ents
.
• Se le
ctiv
emut i
sm. • Complet
ephy si
calass
ess
me nt
.
• Ex press
ivespeec
hdela
y. • ENTr ef
err
al.
• Aut is
m. • Speec
htherapy.
• Posi
ti
verei
nforc
eme nt& enco
ura
geme
nt.
I
nve
sti
gat
ions
• He ar
ingt
estl
ikePur
eTo
neAudi
ome
try
.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
2⇢) ◆⇤
⌅) ⌦
⌦ ⌦%%

Gabr
iel
laAnde
rso
n,a18y
ear
sol
dgi
rlc
amet
oyo
uro
ffi
cewi
thc
ompl
ai
ntso
fga
ini
ngwe
ight
.Ta
kehi
st
ory&
co
unse
l.

Cli
nica
lInfo: MsGa br
iel
laAnders
onpre s
ent
edwithgai
ning5lb si
nlast1mo nth.Shelook
sunde r
we i
ght
fo
rheragea ndheight.
Sheisexer
cis
ing3timesaday.
Shedo es
n'tbing
eo rinducevomit
ing.La
telysheis
ta
kingsmallporti
onsofme a
lsduetofea
ro fg
aini
ngweight.
Sheha snome dicali
ll
ness
es.Nopasthist
oryof
psy
chia
tri
cillnes
s.Curr
entl
yno tt
aki
nga nymedic
ati
ons.
Cli
nica
lCa se:Anorexia

HOPI • Doy out akea nyme di cati

ons?Askde t
ail
s.
• Whe ndi dy o uno ticet hec ha ngei nwe i
ght? • Doy ouc onsumea lc
o ho l?
• Dur ationo fs ympt o ms ? Amo unt/fre
que nc y?
• Amo unto fwe ightg a in? • Doy ouus er ecr
ea t
iona ldrugs
?As k
• Lo we standhi ghestwe ighty o uha d? TRAPPED.
• Ar eyo ua f
raido fg a iningwe ight?
• Ho wdoy out ryt oc o nt rolyo urwe ight? Pas
tPsyc
hiatri
cHi story
• Ho wdoy out hinky o urbo dyl ook s
? • Anys i
mi la
rs ympt omsi npast
?
• Do esy ourbo dywe ight& s hapeha vean • Anyh/ o
impacto ny ours elfo pi nion? ma ni
a/depression/delus i
on/del
ir
ium?
• La stme nstrua l • Anyc ontactswi t
hme nt alhea
lt
h
per
iod/regula ri
ty/co mpl ications? profe
ssi
o nal
s ?
• Anya bdo mina lpa in/ na usea/ vomi t
ing? • Anypa stpro ble
mswi thl aw?
• Bo we lhabits?
• Anys kincha ng es? Famil
yHistory
• Anyi ntole
ra ncet ot e mpe r aturec hanges? • Anyf amilyhi st
oryo fs imil
arcomplai
nts?
• Anyr ecentst res
sor sa tho meo rwo r
k ? • Anyf amilyhi st
oryo fo therpsy
chiat
ric
• Cha ng esins leeppa ttern? il
lnes
ses?
• Fe el
ingo f • Anyf amilyhi st
oryo fs uici
de/
alc
o ho
l/dr
ug
gui
lt/
ho pelessnes s
/he l
pl ess/wo rthless? abuse?
• Cha ng esinmo od?
• Anyt hought so fha rmi ngs e l
f/suici
de ? Soci
alHi
story
• Anyt hought so fha rmi ngs o me onee ls
e? • Suppo rts y
stema tho me /work?
• Anypl ansa tthemo me nt? • Cur r
entlivi
ngs ituat
io n?
• Doy ouf eelpe rsi
ste ntlyc he erful/high? • Re l
ati
onshiphi story
?
• Doy ouha vea nyme dica l
/sur gi
c alil
lness
es? • Educ a
tionhi story?
Askde tai
ls. • Anyr i
sko fphy sical
/sex ual
/mentala
buse?

Di
ff
ere
nti
alDiagnosis Ma
nage
ment
• Ano re
xianervosa
. • Co mplet
ephy si
calasse
ssme nt
.
• Bul imianervosa. • Antidepress
ants.
• Mo oddisorders
. • Supporti
v epsyc
hotherapy.
• Me dica
lcauseofwe i
ghtl
oss
. • CBT
• Bo dyDy s
mo rphicdi
sor
der
. • Ma keplansforwe i
ghtg ai
n.
• Co mmuni tyres
ourcesforeati
ngdis
o r
ders
.
I
nve
sti
gat
ions • Educ a
tionalbroc
hures.
• CBC, el
ect
rol
yte
s,re
na l& Li
verf
unc
ti
on • Admi tifwe ig
ht<85%o fidealwe
ight.
t
est
s. HR<40bpm.
• TSH, bl
oodgluc
ose,ECG. Hypovo l
emia.
• Ur i
neto
xic
olo
gys c
reen. Hypoka l
emia
• Be t
aHCG, LH,FSH. Hypoglycemia.
Hypothe r
mia.
%> ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

AmandaSawye
r,a20y
ear
sol
dgi
rlbr
oug
htt
oyo
uro
ffi
ceb
yhe
rmo
the
rfo
rvo
mit
inga
ndwe
ightl
oss
.Ta
ke
hi
st
ory& c
ounsel
.

Cli
nical
Info:MsAma ndaSawyerpr
ese
nte
dwi t
hv omit
inga
bo utme a
ls.
Sheha sfea
rofweig
htgai
n.H/o
bi
ng i
ng& inducedvomiti
ngpres
ent.H/
olaxat
iveabus
eandexcess
iveexer
cis
e.Shehasnoappar
entps
ycho
-
motororsui
c i
dali
deati
on.Shehasnomedi
calil
lne
sses
.Nopasthist
oryofpsychia
tri
cil
lne
ss.
Curre
ntl
ynot
ta
kinganyme dica
tio
ns.
Cli
nical
Ca se:Buli
mi a

HOPI • Doy out akea nyme di cati

ons?Askde t
ail
s.
• Ons eto fvo mi ting ? • Doy ouc onsumea lc
o ho l?
• Dur ationo fs ympt o ms ? Amo unt/fre
que nc y?
• Ty peo fvomi tus /c
o nt ent s
? • Doy ouus er ecr
ea t
iona ldrugs
?As k
• Pr oj
ec t
il
e/no npr oje ctile? TRAPPED.
• H/ oa bdo mi na lpa in/ site/
t y
pe?
• Doy ouf orcey o urse lftov omit? Pas
tPsyc
hiatri
cHi story
• Doy oubi ng el argea mo unto ffoo d? • Anys i
mi la
rs ympt omsi npast
?
• Amo unto fwe ig htg a in/loss? • Anyh/ o
• Lo we standhi g hestwe ighty ouha d? ma ni
a/depression/delus i
on/del
ir
ium?
• Ho wdoy out r yt oc o nt r
o lyourwe i
ght? • Anyc ontactswi t
hme nt alhea
lt
h
• Do esy ourbo dywe ight& s hapeha vean profe
ssi
o nal
s ?
impacto ny ours elfo pi nion? • Anypa stpro ble
mswi thl aw?
• La stme nstrua l
per
iod/regula rity/co mpl i
c at
ions? Famil
yHistory
• Anys kincha ng es? • Anyf amilyhi st
oryo fs imil
arcomplai
nts?
• Anyi ntole
r anc et ot e mpe r a
turec hanges? • Anyf amilyhi st
oryo fo therpsy
chiat
ric
• Anyr ecents tressor sa tho meo rwo rk? il
lnes
ses?
• Cha ng esins lee ppa ttern? • Anyf amilyhi st
oryo fs uici
de/
alc
o ho
l/dr
ug
• Fe el
ingo f abuse?
gui
lt/
ho pelessne s s
/he l
pl ess/worthless?
• Cha ng esinmo o d? Soci
alHi
story
• Anyt houg htso fha rmi ngs elf
/suicide? • Suppo rts y
stema tho me /work?
• Anyt houg htso fha rmi ngs ome onee lse
? • Cur r
entlivi
ngs ituat
io n?
• Doy ouf eelpe r si
ste ntlyc he er
ful/high? • Re l
ati
onshiphi story
?
• Doy ouha v ea nyme dical/surgi
c alill
ness
es? • Educ a
tionhi story?
Askde tai
ls. • Anyr i
sko fphy sical
/sex ual
/mentala
buse?

Di
ff
ere
nti
alDiagnosis Ma
nage
ment
• Bul imianervosa. • Co mplet
ephy si
calasse
ssme nt
.
• Ano re
xianervosa
. • Antidepress
ants.
• Mo oddisorders
. • Supporti
v epsyc
hotherapy.
• Me dica
lcauseofwe i
ghtl
oss
. • CBT
• Bo dyDy s
mo rphicdi
sor
der
.. • Ma keplansforwe i
ghtg ai
n.
• Co mmuni tyres
ourcesforeati
ngdis
o r
ders
.
I
nve
sti
gat
ions • Educ a
tionalbroc
hures.
• CBC, el
ect
rol
yte
s,re
na l& Li
verf
unc
ti
on • Admi tifwe ig
ht<85%o fidealwe
ight.
t
est
s. HR<40bpm.
• TSH, bl
oodgluc
ose,ECG. Hypovo l
emia.
• Ur i
neto
xic
olo
gys c
reen. Hypoka l
emia
• Be t
aHCG, LH,FSH. Hypoglycemia.
Hypothe r
mia.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
2⇢) ◆⇤
⌅) ⌦
⌦ ⌦%0

Dere
kPa ul
,a65y
ear
so l
dma nadmit
tedinsur
gic
alfl
oorpr
esent
edwit
hstr
ang
ebe
hav
iorf
ort
hepa
st4
ho
urs.Yo
ua r
eoncal
lsur
gic
alre
side
ntforthes
hif
t.Takehi
st
ory& c
ounse
l.

Cli
nic
alInf
o:MrDe rekPaulhadpa r
ti
alri
ghthipreplac
eme nt3daysago.
Hispo stoprecoveryti
llnowhas
bee
nunevent
ful
.Eveningshif
tnurs
eno t
icedsig
nifi
cantchangeinhisbe
havio
r.Hei sagi
tate
d, re
stl
esswi
th
ac
utememo r
ylos
s.Hei sdi
sori
ente
dt oti
me ,
place& perso
n. Heishavi
ngdelusi
onalthoughtsofants
cr
awli
ng.Heisonoralanti
biot
ic
s,ant
ihype
rtensi
ves
,bloodthinner
s.Heischroni
ca l
coholabuser.
Cli
nic
alCase:Del
iri
um

HOPI Pa
stPsy
chi
atr
icHi st
ory
• Whe ndi dy o uno ti
cet hec hang ei n • Anys i
mi la
rsymptomsinpast
?
be
ha vio
r ? • Anyh/ o
• Dur a
tiono fs y mpt oms ? mani
a/depres
si
on/del
usi
on/del
ir
ium?
• Sy mpt omsha vewo r
s enedo rimpr oved? • Anyc ontact
swithmentalhea
lt
h
• Doy ouf eelpe rsi
stentlyc he erf
ul/ high? pr
ofe
ssi
o nal
s?
• Doy ous enset hingst ha to thersa roundy ou • Anypa stprobl
emswithlaw?
don't
?
• Doy ouhe a ra nyv oi
c es? Fa
mi l
yHis
tor
y
• Doy ouf eelr es t
less
/a gitated? • Anyf a
milyhi
st
oryo
fsimil
arcompla
ints
?
• Anyc hang esi nme mo ry? • Anyf a
milyhi
st
oryo
fotherps
ychia
tri
c
• Or ientati
ont ot ime /place /person? i
ll
nes
ses
?
• Anyf ever
/na us e
a/vomi ti
ng ? • Anyf a
milyhi
st
oryo
fsuic
ide/
alc
ohol/
drug
• Anyc hestpa in/a bdo mi na lpain? a
buse
?
• Anyc hang esi nbo we l
/ur inaryha bi ts
?
• La stme al
? Soc
ial
His
tor
y
• Anyc hang esi nmo o d? • Supports
yste
ma thome/work
?
• Anyt houg htso fha r
mi ngs e
lf/
sui cide? • Curre
ntli
vingsi
tuat
ion?
• Anyt houg htso fha r
mi ngs ome onee lse
? • Rela
tio
nshiphis
tor
y?
• Anypl ansa tt hemo me nt? • Educat
ionhist
ory?
• Doy ouha v ea nyme dical/surgicali ll
ness
es? • Anyriskofphys
ica
l/s
exual
/ment
ala
bus
e?
Askde tai
ls.
• Doy out akea nyme dic ations?As kde ta
ils
. T:Tr
eatmenthi s
tory
• Lis tofcurre ntme dic ations . R:Route
• Doy ouc ons umea l
co ho l? A:Addict
ion/t oxi
ci
ty/Amo
unt
Amo unt/freque ncy? P:Pa
tter
no fuse
• Doy ous mo k e ?Dur a t
io n/f r
eque nc y? P:Pr
iorabst
inence
• Doy ouus er e creati
o naldr ugs?As k E:Ef
fect
so fdrug
TRAPPED. D:
Dur at
iono fuse

Di
ff
ere
nti
alDiagnosi
s Ma
nage
me nt
• Ac uteDe l
ir
ium. • Co mpletephy s
ica
lexaminati
on.
• Al coholwit
hdrawal
. • Re -e v
aluatecurr
entme di
cati
ons
.
• Me dic
ati
oninduce
ddel
ir
ium. • Ma inta
inhy drat
ion.
• Se psi
s. • Av oids edati
ves
,narc
otics
,BZD.
• Pl aceinaqui et
,we l
lli
troom.
I
nve
sti
gat
ions • Vi talq1hourly.
• CBC, el
ectr
olyt
es,
rena
lfunc
tio
ntest
s. • I njHa l
o peri
dol5mgI Ms t
atwi
thI
nj
• TSH, bl
oodg l
ucose
,Bloodga
ses Lo r
a z
epa m2 mgIMs t
at.
• Ur i
nal
ysi
swithtoxi
col
ogysc
reen. • Re assurance.
• Bl oodalc
ohollev
els
.
• MSE/ MMSE.
%8 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Cl
ai
reWi gg
ins,
a72y ear
sol
dla
dybroug
htt
oyo
uro
ffi
ceb
yhe
rso
nwi
ths
tra
ngebe
hav
ior
.Ta
kehi
st
oryf
rom
t
hepat
ientandaddr
essherc
onc
erns
.

Clini
calInfo:MsCl air
eWi gg
insisfor
getti
ngt hingsa
ndda il
yta
sksforpa
st1yea r
.He rsympt omshave
becomewo rseforthela
st6mo nths
.Recentl
ys hef o
rgotherwaybackhome.Shel i
vesalo
ne .Sonhasnoti
ced
changesinhe rdr
essi
ngandpoo rhyg
iene.Sheha snoapparentps
ycho-motoro
rs uic
idalideati
on.Shehas
hypert
ensio
n. Nopa s
thist
oryofpsyc
hiat
ricil
lne s
s.Curre
ntlyonora
lanti
hyper
tensives
,stat
ins,zol
oft
,
multi
vita
mins .
Clini
calCas e:Deme nti
a

HOPI • Doy ous mo ke?Dur ati

o n/freque ncy?
• Whe ndi dy ouno ti
c et hec hangein • Doy ouus er ec
reati
ona ldrug s?As k
behavior? TRAPPED.
• Dur ati
ono fsy mpt o ms ?
• Ha veyoufo undy our selfforgett
ingt hing s? Pa s
tPsyc
hiatri
cHi story
(est
ablis
ho nset, dura tion,degree) • Anys i
mi la
rs ymptomsi npa st?
• Doy o ueverg etc onf use dordisorie
nt a t
e d? • Anyh/ oma ni a/depression/de lusio
n/
• Doy o uhavet roubl eunde rst
andingwha t deli
ri
um?
peoplesaytoy o u? • Anyc ontactswi t
hme nt alhe al
th
• Doy o uhavet roubl ef indingther i
g htwo r
ds profe
ssi
o nal
s ?
tosay? • Anypa stpro bl
emswi thl aw?
• Sy mpt omsg e t
tingg radua ll
ywo rseov e r
mo nths? Famil
yHistory
• Ha veyous een, heardo rf el
tanythingt ha t • Anyf amilyhi s
toryofs imilarco mplaints
?
otherpeoplet oldy o udi dn ’
texis
t? • Anyf amilyhi s
toryofo therps ychiatri
c
• Ha veyouno t
ice dac ha ngeiny ours ens eof il
lnes
ses?
sme l
l? • Anyf amilyhi s
toryofs uicide/alcohol/
drug
• Ha veyouha da nyi nc ontinence? abuse?
• Anyc hangesi ng a
it?
• Anymo odc ha ng e
s ? Soci
alHi
story
• Anyf ever/
na usea /
v omi t
ing/abdomi na lpa i
n? • Suppo rts y
stema tho me /wo rk?
s • Cur r
entlivi
ngs it
uati
o n?
• Ha stherebe enac ha ng einpe r
sona l
ity ? • Re l
ati
onshiphi st
ory?
• Doy o uhavea nyme di cal/
surgi
calillne sses
? • Educ a
tionhi st
o r
y?
As kdetai
ls. • Anyr i
sko fphy si
cal/
sex ual/me ntalabuse?
• Doy o utakea nyme dica t
ions?As kde ta i
ls. • Ac t
ivi
ti
eso fda i
lyli
ving& I nstrume nta
l
• Doy o uconsumea lco ho l
? Ac t
ivi
ti
eso fda i
lyli
ving .
Amo unt /
fr
e que ncy?

Di
ff
ere
nti
alDiag nosi
s • MRI/
CTHead.
• Al zheime r
'sdis
eas
e. • MSE/MMSE.
• Mul ti
-Infar
ctdement
ia.
• De me ntiawithLewybodie
s. Ma
nage
me nt
• De pr e
ssion. • Co mpl et
ephy s
icalexaminati
o n.
• Po lypharma c
y. • I nvol
veso c
ialwo rker.
• Li vi
nge nvi
r onme ntasse
ssme nt.
I
nve
sti
gat
ions • Educ ati
o nalbrochures.
• CBC, el
ectrol
yte
s,r
enalfunc
ti
ontes
ts. • Ac cesstoco mmuni tyresources.
• Li verf
unctio
nt e
sts
,Vit
.B12l e
vel
s. • Or ienta
tionc ues
: cl
o c
ks,cal
endars,
not
es.
• TSH, bl
oodg luc
ose,ECG. • Re sourcesforthef amil
y.
• Ur i
nal
ysi
s,uri
netoxi
col
ogyscre
en. • Ac etyl
cho l
inest
era s
einhibit
ors.
• Sa fe
lyho mer egi
stry.
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J
uli
anSmit
h,a56y
ear
sol
dla
dybr
oug
htt
oyo
uro
ffi
ceb
yhe
rhus
bandwi
ths
tra
ngebe
hav
ior
.Ta
kehi
st
ory&
c
ounse
l.

Cli
nicalInf
o:MsJ uli
anSmi thhash/oofchangeinmo o
dforthepast1montha f
terl
oosi
ngherjob
.Shehas
change
sinmo od,sl
eepa ndappet
ite.
Sheha sl
ost10lbsi
nthelast1month.Shehasla
ckofinte
res
tinsoc
ial
act
ivi
ti
es.Shehasnoa ppare
ntpsycho-moto
ro rsui
ci
dali
deati
on.Shehasnome di
cali
ll
nes
ses.
Nopa st
his
tor
yo fpsyc
hiat
ricil
lness
.Curr
entlynottak
inganyme di
cat
ions.
Cli
nicalCase:Depression

HOPI • Doy out akea nyme dic ati

ons?As kdetai
ls
.
• Whe ndi dy o uno ti
cet hec ha ngei n • Doy ouc onsumea lc
o ho lands moke?
beha vior? Amo unt/fre
que nc y?
• Dur ationo fs ympt oms ? • Doy ouus er ecr
e at
iona ldrugs?As k
• Sy mpt omsha v ewo rse
ne do ri mpr oved? TRAPPED.
• Anyr ecents tressorsa tho meo rwo rk?
• Cha ng esins lee ppa ttern? Pas
tPsyc
hiatri
cHi story
• H/ ol acko fint erestrece ntl
y? • Anys i
mi la
rs ympt omsi npa s
t?
• Fe elingo fg uilt/ho pelessness/ • Anyh/ oma nia/depression/del
usion/
helpless/wo rthles s
? deli
ri
um?
• La c ko fene rgy ? • Anyc ontactswi thme nt alheal
th
• Cha ng esinmo o d? profe
ssi
o nal
s ?
• Ar ey ouc r
y i
ngal ot? • Anypa stpro ble
mswi thl aw?
• I syo urmo oda lway slowo rita l
terna t
es?
• Anyc hang esi nc onc entrati
o n? Famil
yHistory
• Anyc hang esi na ppe ti
te? • Anyf amilyhi st
o r
yo fs imil
arco mplai
nts
?
• Anyc hang esi nwe ight? • Anyf amilyhi st
o r
yo fo therpsychiat
ri
c
• Anyc hang esi nme mo r
y ? il
lnes
ses?
• Doy ouf eelslo we ddo wn? • Anyf amilyhi st
o r
yo fs uici
de/alc
ohol/
• Doy ouf eelre stles
s /
a gi
ta t
ed? drugabus e
?
• Anyt houg htso fha rmings elf/suicide?
• Anyt houg htso fha rmings o me onee lse
? Soci
alHi
story
• Anypl ansa tt hemo me nt ? • Suppo rts y
stema tho me /wo r
k?
• Doy ouf eelpe r si
stentlyc heerful/high? • Cur r
entlivi
ngs ituat
io n?
• Doy ous enset hingst hato the r
sa roundy ou • Re l
ati
onshiphi story
?
don't? • Educ a
tionhi story?
• Doy ouha v ea nyme dical/s
urg i
c a
li ll
ness
es? • Anyr i
sko fphy sical
/sex ual
/me nta
labuse
?
Askde tai
ls.

Dif
fer
enti
alDiagnosi
s Ma
nage
me nt
• Ma jo
rDe pres
siveEpisode. • St ar
tSSRI .
• Adj ustmentdisor
derwi t
hde pres
sedmood. • Ps yc
ho t
herapy/CBT.
• Bi pola
raffec
tivedis
order. • Educ ati
onalbr oc
huresabo utdepressi
on.
• Anx i
etydis
order. • I nf
oa boutt
hes i
deeffec
tso fme dica
tio
ns.
• Empha si
sonl ongt e
rm ma na ge
me nt,
fol
low
I
nvest
iga
tions upandc ompl i
ance.
• CBC, elec
trol
ytes,
renalfunc
t i
ontest
s. • Re fer
raltoco mmuni t
yreso urc
es.
• TSH, bloodglucose
,urinal
ysis
. • Co ntract
:Ptt ocontactyou/ f
amilydoctor
/
• MSE/ MMSE. near
estemerg ency
/fri
end/fami l
y/cri
si
shelp
li
neincaseo fsui
cidalorho micidali
deati
on.
%9 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Davi
dRo senber
g,a26yea
rso
ldmanbroug
htt
otheERb
ythepo
lic
ebe
caus
ehewa
sthr
owi
ngs
tone
sona
publ
icbui
lding
.Takehi
st
ory& c
ouns
el.

Clinic
alInf
o: MrDa vi
dRosenber
gpr e
sent
edwithi
rra
tionalbeha
viorf
orthepast10days
.Heishaving
raci
ngthoughts,
incr
ease
dacti
vit
y,decr
eas
edsle
epandincre
a s
edvocal
iz
ati
on.Heha sco
nstantf
li
ghtofideas
duringthei
ntervi
ewwitheas
ydistra
cti
bil
it
y.Heisr
est
les
swhi l
esit
ti
nganda tt
imesagi
tat
ed.Nome dic
a l
il
lness
esbutisachro
niccoc
aineabuser
.
Clinic
alCase:Ma ni
a

HOPI • Doy ouha vea nyme dica l

/s
urgicalill
ne s
ses?
• Whe ndi dy o uno ti
cet hebe ha vi
oral As kdeta
ils.
chang e
s? • Doy out akea nyme dic ati
ons?As kde tails
.
• Dur ati
o no fs ympt oms ? • Doy ouc onsumea lc
o ho lands mo ke?
• Sy mpt omsha vewo rs
ene do rimpr ov e
d? Amo unt/fre
que nc y?
• Anyr ecents tr
e s
sorsa tho meo rwo rk? • Doy ouus er ecr
e at
iona ldrugs?As k
• Doy oug ete asil
ydi stractedwhi l
et alki
ngo r TRAPPED.
work i
ng ?
• Di dy ouha ver ecklessdr ivi
ng& dr inki
ng Pas
tPsyc
hiatri
cHi story
epi
so de? • Anys i
mi la
rs ympt omsi npa s
t?
• Ha veyo ug o nef orsho ppings prees/ • Anyh/ oma nia/depression/del
usio n/
gambl i
ng /e xcessivespe nding ? deli
ri
um?
• Doy ouf eellikeas pe ci
a lpersonwi thspecia
l • Anyc ontactswi thme nt alheal
th
tal
ent,po we ro ro nami ssion? profe
ssi
o nal
s ?
• Dope oples ayy ouj umpf romt opict otopi
c? • Anypa stpro ble
mswi thl aw?
• Di da ny ones a ythaty ouha v eincr
e ased
act
ivity/ene r
gy /appe t
ite/rest
less/
agitati
on? Fa mil
yHistory
• Cha ngesi ns leeppa ttern? • Anyf amilyhi st
o r
yo fs imil
arco mpl ai
nts?
• Di da ny ones a ythaty oua remo r
et alkat
ive • Anyf amilyhi st
o r
yo fo therpsychia t
ri
c
thanus ual? il
lnes
ses?
• H/ ol acko finterestrece ntl
y? • Anyf amilyhi st
o r
yo fs uici
de/alc
o hol/drug
• Fe eli
ngo fg uilt/
ho pelessness/hel
ple ss
/ abuse?
worthlessne ss?
• Cha ngesi nmo od? Soci
alHi
story
• Anyt ho ug htso fha rmings elf/s
uicide? • Suppo rts y
stema tho me /wo r
k?
• Anyt ho ug htso fha rmings o me o
nee l
se? • Cur r
entlivi
ngs ituat
io n?
• Anypl ansa tthemo me nt? • Re l
ati
onshiphi story
?
• Doy ous enset hingst ha tothersaroundy ou • Educ a
tionhi story?
don't? • Anyr i
sko fphy sical
/sex ual
/me ntalabuse ?

Di
ff
ere
nti
alDia g
nos i
s Ma
nage
me nt
• Co c
aineinducedMa ni
ace
pis
ode
. • St ar
tMo ods t
abili
z er
s-
• Bi pol
ardi so
rder
. Lit
hium/ Valproate/CBZ.
• Pe rs
ona l
itydis
order
. • Ps yc
ho t
he ra
py/CBT.
• Sub st
a nceabuse. • Admi ti
nc a
seo facutema nia.
• I nf
oa boutthes idee f
fec
tso fmedica
tio
ns.
I
nve
sti
gat
ions • Empha si
so nlongt e
rm ma nagement,
fol
low
• CBC, e
lec
trol
yte
s,re
na lfunc
ti
onte
sts
. upandc ompl i
anc e.
• TSH, bloodgluc
ose,urinal
ysi
s. • Re fer
raltoc ommuni t
yresources
.
• VDRL, HIV. • Co ntract
: Pttoc ontactyou/famil
ydo ct
or/
• Ur i
netoxi
colo
gys c
reen. near
esteme rgenc y
/fri
end/famil
y/cri
si
shelp
• Ur ge
ntpsychi
atr
icconsult. li
neincaseo fsuicidalorhomi c
idali
deati
on.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
2⇢) ◆⇤
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BradDa niel
s,a22y ear
soldma ncamet oyouroff
icewithl
ightheade
dness,t
rembl
ingandc hes
tpainfort
he
past4ho ur
s.Takehi s
tor
y& c ounsel
.
Clini
calInfo:MrBr a
dDa nielsisauniver
si
tyst
ude ntwhopresent
edwithsuddenonsetofl
ightheadedne
ss,
tre
mblingo fbodya ndchestpainpri
o rtohispr
esentat
ioni
nc l
ass.
Hea ls
oc o
mplai
ntso fpa
lpi
tati
onsand
short
nessofbreat
h. Heha dsimilarepis
odesinthepast.
Nopa sthi
stor
yo fps
ychi
atri
corme di
calil
lne
sses
.
No tt
akinga nyme dic
ati
onsc urr
entl
y.
Clini
calCas e:PanicAttac
k

HOPI • Wo rrya boutc onseque nc eso fano ther

• Whe ndi dy ouno ti
c ethes ympt oms? atta
ck ?
• Dur a t
iono fsympt oms ? • Anyt ho ught sofha r
mi ngs elf/
suicide?
• Sy mpt omsha v
ewo rsenedo rimpr oved? • Anyt ho ught sofha r
mi ngs ome o
nee l
se?
• Anyr ec
e nts t
ressorsa tho meo rwo r
k? • Doy o uha vea nyme di ca l
/surgicalill
ne s
ses?
• Doy ouha vee xc essiv
es we a ti
ng ? • Doy o ut akea nyme dic ati
o ns?As kde tails
.
• Doy oue xpe r
ienc et r
emo rs? • Doy o uc onsumea lc
o ho l/
s mo ke?
• Doy ouha veuns teadine ss/dizziness
? Amo unt /fre
que nc y
?
• Doy ous ensethi ng stha to thersaroundyou • Doy o uus er ecr
eationa ldrug s?As k
don'
t?(De re a
li
z ation) TRAPPED.
• Doy oue verfee lyo ua reo utsideo fyour
sel
f?
(Depersonalization) Pas
tPsyc
hiatricHi story
• Doy ouha vee xc essiv
ehe artr at
e ? • Anys imi la
rs ympt omsi npa st?
• Na usea/vomi ti
ng ? • Anyh/ oma nia/depres sion/de l
us i
on/
• Anyt i
ng l
ing /
pa resthes i
as? deli
rium?
• Anys hortnesso fbr eath? • Anyc ontactswi t
hme nt alhe al
th
• Anyf ea
ro fdy ing /l
o osingc o ntrol
/going professi
o nal
s ?
cra
zy? • Anypa stpro ble
mswi thl aw?
• Doy ouha vec he stpa in?
• Doy ouha vec hills/cho kings ens a
tio
n? Famil
yHistory
• Cha ng esins l
eeppa ttern? • Anyf a milyhi st
oryo fs imilarco mpl ai
nts?
• Fe el
ingo fg uil
t/ho pelessne ss/helpl
ess/ • Anyf a milyhi st
oryo fo therps ychia t
ri
c
worthle
ss? il
lnesses?
• Anyc hang esinmo od? • Anyf a milyhi st
oryo fs uicide/alc
o hol/drug
• Anyc hang esinc onc ent r
a t
io n? abuse?
• Anyc hang esina ppe tite/we ight?
• Anyc hang esinbo we lha bits? Soci
alHi
story
• Anyc hang esinme mo ry? • Suppo rts y
stema tho me /wo rk?
• Doy ouf eelslowe ddo wn? • Cur r
e ntlivi
ngs it
ua t
io n?
• Doy ouf eelrestless/agitated? • Re l
ationshiphi st
o r
y?
• Amo unto fc af
fe i
nei nt ake? • Educ ationhi stor
y ?
• Anya ntici
pa t
or ya nxiety? • Anyr isko fphy si
c a
l/sex ual/me ntalabuse ?

Di
ff
ere
nti
alDiagnosis Ma
nage
me nt
• Pa ni
cAt ta
ck . • St ar
tSSRI .
• Pa ni
cdisorder. • Ps ychotherapy/CBT.
• Anx iet
ydiso r
der
. • Educ a
tionalbro chure
sabouta nx i
etya t
tac
ks.
• Mo oddisorder
. • I nf
oa boutthes i
dee f
fec
tso fme dicati
ons.
• Empha sisonl ongt er
m ma nageme nt,fol
low
I
nve
sti
gat
ions upandc ompl i
ance.
• CBC, el
ect
rol
yte
s,r
enalfunc
ti
onte
sts
. • Mus cl
er el
axa t
ion,deepbreathing&
• TSH, bl
oodgluc
ose,
urinal
ysi
s. biof
eedback.
• ECG. • Co nt r
act:Pt.toc onta
ctyou/ f
ami l
ydo ctor
/
near
e s
te merg e
nc y/f
ri
end/f
a mily/cri
sishel
p
li
neinc aseo fsui
c i
dalorhomi cidalideat
ion.
>- ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Liam Pinke
rton,a24y e
a r
soldma lewa sbr o
ug httotheERwi t
hco mplai
ntsofal
ienatt
acks.Takehis
tory&
counsel
.
Clinic
alInf
o:MrLi am Pink e
rto
ni sbro ughtb ypoli
cewithco
mpla i
ntsofbei
nga t
tack
edb yali
ensi
nthel a
st
48ho urs
.Heistalki
ngt ohimsel
fa ndav oidingdirec
teyecont
act
.Hei sres
tle
ssandagita
tedandfeel
s
threa
tened.
Hei sheari
ngs tr
angevo i
cesf o
rt hepa s
t1mo nthal
ongwi t
hdisorga
nizedspeec
ha ndbehavi
or.
Hei sachroni
cco c
aineuserforthepast3y ear
sa ndincr
eas
edconsumptioninla
st48ho urs
.
Clinic
alCase:Schizophrenia

HOPI • Ge temo ti
ona lo rexcite da boutt hing syou
Tho
ughtphe no me na : areuse dt o?
• Thi nky ourt ho ug ht sa reinte rfer
e dwi thin • Ha vedr i
v ea nda mbi tio nfo rany thinga tthe
anywa y? mo me nt?
• Thi nko the rsc anr ea dy ourt ho ug hts? • Anymo odc hang esrece ntly?
• Thi nka no ut sidee nt i
t yisa ffecti
ngy our • Doy o uf eelr e
stless/
a gitated?
thoug hts? • Anyc hang esina ppe tite/we ight?
• He a re cho’so fy o urt ho ug htsl ikeav oice
? • Anyf e ver/
na usea /vomi ting/trauma ?
Del
usi
ons: • Cur r
e ntl
yo na nyme dic ati
o ns?
• Any thingbo ther ingy o ua tt hemo me nt? • Doy o uc ons umea lc
o ho l?
• Ev erf elttha ts ome o nei so utt og e tyou? Amo unt /freque nc y
?
• Di f ferentunde rst andi ngo ft hing st oo t
her • Doy o us mo k e?Dur a t
io n/freque ncy ?
peo ple ? • Doy o uus er ecreationa ldrug s?TRAPPED?
• Doy oug eta nys pec ialinfor ma ti
o nf rom Pas
tPs yc
hiatricHi stor y
thing swhi chha ppe n? • Anys imi lars y
mpt omsi npa st?
• Doy oug ets pe c ialme ssageso r • Anyh/ oma nia/de pres sion/de lusion/
communi c
a tio nf rom ne ws pa pe r
s,r a
dio , deli
rium?
tel
e visiono ra nyo t
he rs ourc e? • Anyc ontactswi thme nt alhe alt
h
• De lus ionso fc ont rol;inf l
ue nceo rpa ss
ivit
y: professi
o nals?
• Doy ouf eelt ha taf orc ecanc ontro lo r • Anypa stpr oblemswi thl aw?
infl
ue nc ey o u?
• Thi nkt hats o meo fy oura ct i
o nso rt hought Fa milyHistory
areno tbe ingc ont ro ll
e db yy ou? • Anyf a milyhi storyo fs imilarc ompl aints?
Hal
luc
inati
o ns : • A nyfa mily h i
story ofo th e
r psych iatri
c
• He a rv oiceswhe nt herei snoo nepr e s
ent? il
lnesses?
• Do e ss ome o net alkt oy ou? • A nyfa milyhi storyo fs uicide/alcoho l/
drug
• Ho wma ny?Whoa ret he y?Wha tdot hey abuse?
say? Soci
a l
History
• Dot he ye ve rt elly out oha rm/ k i
lly ourse
lfor • Suppo rts ystema tho me /wo rk?
othe rs? • Cur r
e ntlivings it
ua t
io n?
• Ho wo ftendoy o uhe arv oice s? • Re l
ationshiphi s
to ry
?
• Ho wdo esi tma k ey ouf eel? • Educ ationhi s
tory ?
• Ca ny ouc o ntr olo rs topt he m? • Anyr isko fphy si
c al
/sex ual/me ntala buse?
• Bl unt e da f
f ect/Apa thy ,l
o sso fdr ive?

Dif
fer
enti
al Diagnosi
s Ma
nage
me nt
• Sc hizophreni
a. • Admi ti
nho spitalunderFORM 1.
• Sub st
anceinducedAcutePsychosi
s. • St ar
tAnt i
-Ps y
cho t
ics
.
• Ac uteDe l
usi
onaldis
order. • I njHa l
oper
ido l5mgI Ms t
at.
• Sc hizoaffe
cti
vedisor
der. • Ur gentpsychiatr
icconsul
ta
tio
n.
I
nvest
iga
tions • De t
oxif
ica
tionpr ogra
m.
• CBC, el
ectr
olyt
es,r
enalfunct
iontes
ts. • I nvol
vesoci
a lwor k.
• Li verfuncti
ont e
st,
bloodg a
ses.
• Bl o odgl
uc os
e,uri
nal
ysis
.
• Ur i
netox i
col
ogyscree
n.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
2⇢) ◆⇤
⌅) ⌦
⌦ ⌦>

EricaMc Ca ini
sa16y ear
so l
dg i
rlbro
ug htt
otheERwi thASAov er
dose.Shei ss
tabi
lizednow.Take
his
to ry& counse
l.
ClinicalInf
o:MsEr icaMc Cai
na16y earsoldsc
ho olgoi
nggir
ltook30tabso fAspiri
na f
tersmashi
ngher
par
e ntscarinatree
.Sheattempte
dt ocommi ts
uici
detopreve
ntemba r
ras
sme nt.Shewe nttoherfri
ends
housea f
tertheacci
dent.
He rgra
ndmabr oughthertotheER.Ha sh/oprevi
ousa tt
empt1y e
arago.I
s
cur
r entl
yc o
nsul
tingapsychi
atr
is
to nre
gularbasi
s.Pr
e s
entl
yonanti
depres
sants.ShowEMPATHY!
ClinicalCase:Suici
de

HOPI • Doy ouus ere c

rea t
iona ldrug s?As k
• Ana l
y zet hea t
te mpt - TRAPPED.
Whe n?/Wha tme tho d?/So urceo f
me tho d?/Ci rcums tanc eswhi c hle adto Pa s
tPsyc
hiatri
cHi st
or y
thea ttempt ? • Anys imila
ra tt
e mpt sint hepa s t
?
• Wha twe rey ourt ho ught swhi l
ehur ting Out c
o me/admi ssion,ifa ny?
yourself? • Tr eatmentg ivenf orsuc ha tt
empt s?
• Wha tdidy o ut hinkwo uldbet heo utcome? • Anyh/ oma ni a/depr ession/de lusi
on/
• Cha ng esinmo o d? deli
ri
um?
• H/ olac ko fi nterestr ecently? • Anyc ontactswi t
hme nt alhe al
th
• Fe eli
ngo fg uil
t/ho pe l
essne ss/he lpless/ profe
ssional
s?
wo r
thl ess
? • Anypa stpro bl
emswi thl aw?
• La cko fene rgy/co ncentra t
io n?
• I syourmo o da lwa yslo wo ri ta l
t erna t
es? Famil
yHistory
• Anyc hang e sina ppe t
ite/we ight? • Anyf amilyhi s
toryo fs uicidalattempts?
• Doy ouf ee lrestless/agitated? • Anyf amilyhi s
toryo fo therps ychiat
ric
• Anyt ho ug ht so fha rmi ngs o me o nee lse? il
lnes
ses?
• Anypl ansa tthemo me nt ? • Anyf amilyhi s
toryo fs uicide/alco
hol/dr
ug
• Doy ous ens et hing stha tot he r
sa r
o undy ou abuse?
don't?
• Doy ouha vea nyme dical/sur gi
c alillness
es? Soci
alHi
story
Askde tai
ls . • Suppo r
ts y
stema tho me /wo rk?
• Doy out ak ea nyme dications ?As kde tai
ls
. • Cur r
entlivi
ngs ituation?
• Doy ouc o ns umea lcoho l
? • Re l
ati
onshiphi story?
Amo unt/fre que ncy ? • Educ at
ionhi st
o r
y ?
• Doy ous mo k e
?Fr eque ncy/dur at ion? • Anyr is
ko fphy sical/
sex ual/me ntala
buse?

Di
agnos
is As
ses
sSui cidalris
k :SAD PERSONS
• Sui c
ida
lAt
tempt
. Sex-Ma le>fe male
Age-Bi mo dal:15-25y e
arsand>65y ea
rs.
I
nve
sti
gat
ions Depre ss
ion
• CBC, elec
trol
yte
s,re
nalfunct
ionte
sts
. Previ
o usattempt s
• Li verf
unctio
nt e
sts
,Bloodg a
ses
. Ethano luse
• Se .sal
ic
ylat
elevel
sq2htilll
eve
lsf
all
. Rati
o nalthinking
• Bl oodglucos
e,uri
nalys
is
. Suic
idei nf a
mi ly
Organi ze
dpl an
Ma
nage
ment Nos uppo rt
• Admi tunderFORM 1. Sick
ne ss
• Ga s
tr i
cLa vag
e. Ba
sedont hes corefromt hescal
e:
• Urinea lka
lini
zati
on. 0-
2-Se ndho mewi thfamil
y.
• Urge ntpsychi
atri
ceval
uati
on. 3-
4-Cl osefo l
lowup ,consi
deradmis
si
on.
• Arrang efamil
yme eti
ngandinvo
lves
oci
al 5-
6-St ronglyconsideradmiss
ion.
wo
rk er. 7-
10-Admi t.
• StartLi t
hium orClozapi
ne.
> ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Br
andonRodri
gue
s,28y
oungma nc
ome
swi
thr
ece
nto
nse
tofba
ckpa
ina
ndl
imp
.Ta
kef
ocus
edhi
st
orya
nd
pr
efo
rm af
ocus
edexami
nat
ion.

Clinic
alinf
o :MrBr a
ndo nRo dri
gueshadas uddenons etofshar
plowerba
ckpai
n2da ysagoaft
erli
ft
ing
heavyboxesa tho me.Painisl
o c
atedinthel
umba ra r
ea ,
g r
ade8/10andisc
ons
tantl
ypres
ent.Hehas
numb nes
sa ndpa rest
he s
iaspr
esentinhisl
eftlegforthepa s
t12ho urs
.Noweak
nessorlos
sofsensa
tio
nin
thelowerli
mbs .Nou ri
naryrete
ntionorbowe li
ncontinence.Hedo e
snots
mokeo rco
nsumea l
cohol
.O/E
therei
stende rnessi
nt heL4–L5a rea& decreas
edse nsat
ionintheL4–L5de r
ma t
omaldist
ri
buti
on.
Clinic
alCas e: BackPa i
n

HOPI Pa
s tHi s
tor y
• OCD PQRSTUVW +AAA • Doy ouha v
edi abet
esorhy pertension?
• Ho wdi dits t
a r
t?Sudde no rg radua l. • Ar ey ouo nanyme dic
ations?
• I sitg ettingwo rse/bettero rnoc hang e
sin • Ar ey oua l
ler
gict oanyme dicat
io ns?
thes ympt oms ? • Anys urgerie
si nthepast?
• Si nceho wl ongha v eyo uno ti
c edt hebac k
pain? Fa
mi l
yandSoc ialHistory
• Whe rei st hepa inlo cated?( Pa inwo r
sein • Doy ous mo ke?Dur ati
on& f reque ncy
.
backt ha ni nbut tock so rle gssug g e
s t
s • Doy ouc o
nsumea l
cohol?Dur ation&
me cha nic albackpa in. Pa inwo rseinbut tock
s f
re quenc y.
sugg estsr adiculopathy ) • Doy ouus erec r
eati
onaldrug s
?TRAPPED.
• Ty peo fpa in- s
ha r
po rdul l? • Anyf ami l
yhistoryofcanc e
rs/me dic
al
• Do est hepa inr adi
a t
eo rs ho otany whe r
e? i
llnesses?
• Se ve rityo fpa ino nas ca l
eo f1- 10. • Er e cti
ledy sf
unc t
ion(Ca udaequi na
• Doy o urs ympt omsc hang ewi tht ime ? s
y ndr ome )
• Anya g grav at
ingo rr el
iev ingf acto r
s?(Pa i
n
wo rsel yingdo wna ndbi lateralle gwe akness RED FLAGS( BACKPAI N)
sugg estss pinalsteno si
so ra nky l
o si
ng Bo welo rBl adderdy sf
unction
spondy losis,) Ane st
he sia(Sa ddle
)–pe r
inealnumbne ss
• Ef fec to na cti
v i
tieso fda il
yl iving ,f
unc t
ional Co nst
itutiona lSympt oms–Ma l
ignancy
li
mi tation? K: Chr oni cdisease
• H/ of ev er/fatigue/we ightl o
s s/night Pa r
est
he sias
swea ts? Ag e>50
• Bur ningmi ct
ur ati
on, j
o intpa in, uve i
ti
s? IVdr ugus er
s
• Mo rnings ti
ffness?As so ciatednumb ness, Ne uromo torde f
ic
its
we akne ss?
• Bl adde rre t
ent i
on/ bo we linc ontine nce?

Di
ff
ere
nti
alDiagnosis Ma
nage
ment
• Di sche r
niat
ion. • Re a
ssuranceande ducati
onifnoc ause(70%
• Spo ndy l
oart
hropa
thy
. i
mprovein2we e
k s,90%in6we e
k s)
• Ra diculopat
hy. • Limitedbe dres
t.
• Me chanica
lbackpai
n. • Ac t
ivit
ymo dif
icat
ion.
• He at
/Co ldther
apies.
I
nve
sti
gat
ions • Lo ws t
ressaer
obicac t
ivi
ti
esinfi
rst2we eks.
• Lumbo -
sac
ralX-
ray
. • Enc oura
g eear
lyreturntowo rk
/act i
vit
ies
.
• NSAI DS/Ac et
ami nophen.

Sur
ger
yindi c
atedin
• Ca udaEqui na
.
• Wo r
seni
ngne uro
logi
caldef
ic
it
.
• I ntrac
tabl
epa i
nno tre
spondi
ngto
conservat
ivetr
eatment.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
✏⌥⌅
⇡✓⌅
) ⌦
⌦ ⌦>%

Nic
oleDav
y,a75ye
arsol
dladypres
ent
edwithe
nla
rgi
ngmol
eonhernos
e.Ta
keaf
ocus
edhi
st
orya
nd
pe
rfor
mfocus
edphys
ica
lexa
mi na
tio
n.
Vi
tal
s:BP-120/
88mm Hg ,HR-86/ min,
RR-12/min,
Temp-37.
0°C

Clinica
l Inf
o:MsNi coleDa vyhasanenla
rgingmo l
eo nhe rnosewhi chi
schangingcolorands hapeovert
he
past1mo nt
h.SheisCa uca
sianreti
redwoma nwhos pends6mo nthsinFlori
daduringwi nte
rsinCa na
da .
Rece nt
lynotic
edirr
egularedgesofhermo l
ea ndgotconcerned.Shewo rke
da saradia
tio
nt echnic
ianfor30
yearspriort
oreti
rement.Sheha dasimil
armo lewhichwa scancer
o usandremoved10y earsago.O/E:The r
e
isasma ll0.
5x0.5c m pear
lypapuleonherlatera
lle
ftsideo fno
s e
,wi t
hirr
egula
rroll
edo utma rgi
nsand
minima ldis
charg
e.
Clinica
l CaseDiagnosis
:Ba s
alCellCarc
inoma .

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha vediabetesorhy pert
ension?
• Ho wdi di ts tar t?Sudde no rgradua l
. • Ar eyo uona nyme di c
ati
o ns?
• Isitgettingwo rs e/bett
erornoc hangesin • Ar eyo ualle
rgictoa nyme dicat
ions?
t
hesympt o ms ? • Anys urgeri
esinthepa st?
• Dur at
iono fthemo l
e? • Pa s th/orecurrentinfect
ions?
• Lo ca
tiono ft hemo l
e?
• Wha tc ha ng esha v
ey ouno t
icedi nthemo l
e? Fa
mi l
yandSoc i
alHi st
ory
• Anyi t
chi ng ? • Doy ous mo ke
?Dur ati
on& f re
que ncy
.
• Anyul cer ation? • Doy ouc onsumea lcohol?Dur at
ion&
• Anydi scha rgeo rbl e
edingno t
iced? frequency.
• Anyc ha ng ei nc oloro ft
hemo l
e? • Doy ouus erecrea
tionaldrugs?TRAPPED.
• Anyo the rs us pic io
usmo le
se l
sewhe re? • Anyf amilyhist
o r
yo fcanc e
rs/me dic
al
• Amo unts une x po sure? ill
ne s
ses?
• Anyr adia tione xpo sure? • Oc cupa t
ion?
• Anys we llingno tic
e dinthebo dy ?
• Anyf ever /na use a/vomi t
ing/decr
e ased
a
ppeti
te?
• Anywe ightl oss/ nightsweats?
• Anyhe a da che /c hestpa i
n/bonypa in?
• Anyv isua lc ha ng es?
• Anyc ha ng esi nbo we l& urinaryha bi
ts?

Di
ff
ere
nti
alDiagnosi
s Ma
nage
me nt
• Ba salCellCarci
noma. • Co mpletephysi
calexaminat
ion.
• Squa mo usCellCarc
inoma. • El ect
rode s
si
cati
on& c ur
ettag
e.
• No dul
arma l
ignantmelano
ma . • Sur gi
ca lexc
isi
on±mi crosc
opica
lly
• I nt
r a
der
ma lme l
anocyt
icnevus
. contr
olledsurger
y.
• Cr yothe r
apy.
I
nve
sti
gat
ions • 95%c urerateinles
ionsles
sthan2c m.
• Punc h/e
xci
si
onbi
ops
y. • Li fel
o ngfoll
owup .
• I miquimo d5%c rea
ml ocal
ly,
ifsur
gica
l
tr
eatme ntnotpossi
ble.
>> ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

J
aco
bSimpson,
62yea
ro l
dma npre
sent
stotheEmerg
encyDepa
rtme
ntwit
h12ho ur
ssupr
apubi
cdi
sco
mfo
rt
a
ndina
bil
it
ytouri
nat
e.Takeafo
cusedhi
st
ory& pe
rfor
m af
ocus
edexa
minat
ion.

Cli
nicalInfo:MrJ a
co bSi
mpsonprese
ntedwi t
ha c
uteuri
naryr
ete
nti
onfort
hepast12hour s
.Hei sha
ving
dif
fi
cul
t ypass
ingurinefort
hepast4mo nths,whi
chha sg
radua
ll
yinc
rea
sed.Hehashesi
tancy,urg
ency
,
inc
reas
e dfre
que nc
ya ndweakst
ream.Nohe ma t
uri
ao rUTI.O/Ethe
reisapal
pabl
esupra
- pubicmass
.
Cathet
e ri
zat
iony i
el
ds1200ccuri
ne.
Cli
nicalCa s
e: BenignPros
tat
icHy pe
rpla
s i
a

HOPI Pa
stHistor
y
• OCD PQRSTUVW +AAA • Doy ouha v edi abete
so rhy per
tension?
• Ho wdi di ts tart?Sudde no rg radua l
. • Ar eyo uo na nyme dications ?
• Isitg et
tingwo r
s e/betterornoc hang esi
n • Ar eyo ua llergict oanyme dica
tions?
t
hes ympt oms ? • Pr evi
o usr ena lco l
ic/di agno s
edpr ostat
e
• Dur ationo fi nabilitytopa s surine? hypertrophy ?
• Anypa ina sso c
iated? • H/ O pros t
a tec ancer
, pro s
tati
sm,
• Lo cati
o no fpa in? nephro l
ithiasis,UTI s?H/ O pel
vicr adi
ati
on?
• Ty peo fpa i
n–s ha rpo rdul l? • Anyh/ opa sts urgeri
e s?TURP?
• Se veri
tyo fpa ino nas caleo f1- 10.
• Doy ours y mpt o msc hang ewi tht i
me ? Fa
mi l
yandSoc ialHi story
• Di ff
icultyi nitiatingo rma intainingur inar
y • Anyf ami lyhi storyo fca ncer/similar
s
tr
e am? compla i
nt s?
• H/ O we ak /
int errupte dstrea m/ • Cur rentlyi nar elat
ions hip?
• Fee l
ingo finc ompl e tebladde re mpt ying? • Pr act
icings afese x?
• Anyno c turia/ur g ency/i ncreasedf requency? • Doy out hi nky oua r
ei nr iskofge t
tingSTIs?
• Co loro fur ine ?Anybl oodi nur ine? • Doy ous mo k e?Dur a t
io n& f r
eque ncy.
• H/ Or ec ur r
e ntur inaryi nfections ? • Doy ouc o ns umea lc
o ho l
?Dur a
tion&
• H/ Or ena lpa ino rg roinpa in? fre
quenc y.
• H/ Of ev er,ni ghts we ats,we ightl o
s s
,fati
gue? • Doy ouus er ec r
eatio
na ldr ugs?TRAPPED.
• Anybo we lco mpl aints?
• Anype rine alnumb ne ss/le gwe a kness?

Di
ff
ere
nti
alDiagnosi
s Ma
nage
me nt
• Be nignProst
ati
cHy per
pla
sia
. • DRE( Di git
a lrect
alex a
mi nation).
• Ur inar
yTr a
ctInfe
cti
on. • Wa tc
hf ulwa iti
ng(50%r esol
ve
• Pr ost
ati
ti
s. spontaneo usl
y )
.
• Pr ost
ateCancer. • Li f
e s
tylemo dif
icati
ons–e veningf l
uid
res
tri
ctions ,
pl a
nne dvo i
ding .
I
nve
sti
gat
ions • Ur ologicalco nsult
ati
o n.
• Ur ea/Creati
nine
. • Me dic
a ti
o n–Al pha-adrenergica nt
agoni
st
s
• Ur i
nalysi
s,c
ult
ure& s
ensit
ivi
ty
. (Teraz
o sin,Do xazoci
n, Tams ulosin)
.
• Pr o s
tat
eSpe c
if
icAnti
gen(PSA). • 5- al
pha -reduc t
aseinhibitors(Fi nes
teri
de)
.
• Re nalandpelv
isul
tr
asound. • Sur gery( TURP ,openpr ostat
e ct
o my).
• Cy stos
copy. • Mi nima l
lyinv asi
ve(St e
nts,Mi crowave
thera
py ,La s
era bla
tion,Cr yotherapy,
HI FU,
TUNA) .
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
✏⌥⌅
⇡✓⌅
) ⌦
⌦ ⌦>0

Ly
diaJo
nes,a30y
e a
rsol
do f
fi
cela
dypres
ente
dtoyourof
fi
cewi
thr
ightha
ndnumbne
ssa
ndwe
akne
ssf
or2
mont
hs.Ta
keafocuse
dhist
oryandaddr
esshe
rconc
erns
.

Cli
nica
linf
o:MsLy diaJonespr
esentedwi
thg r
adualons
etofrig
htnumbnessandweaknes
sfo
rthepa
st2
months.
He rsymptomsha veworsened.As
soci
atedwithpar
est
hesi
asandpa
ininfing
ersatt
heendoft
heday
.
Shehasdif
fi
cult
yo peningjar
s,t
urningkey
sandni g
htpains
.
Shehasnome dic
alill
ne s
s.Notona nymedic
ati
ons.Sheisa
no f
fi
ceadmini
st
rat
o r
.
Cli
nica
lCa s
e:Ca rpalTunnelSyndrome

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy o
uha vediabet
esorhy pert
ension?
• Ha nde dness–l e fto rri
g ht? • Ar eyouo nanyme dic
ati
o ns?
• Ho wdi ditsta r
t?Sudde no rg r
adua l
. • Ar eyoualle
rgictoanyme dicat
ions?
• Isitget t
ingwo rse/ bett
ero rnoc hangesin • Anys urgeri
esinthepast?
t
hes y
mpt oms ?
• Dur ati
o no fnumbne s
s? Fa
mi l
yandSoc ial
Hi st
ory
• Lo cat
io no fnumb ness? • Doy o
us mo ke
?Dur ati
on& f re
que ncy.
• Anypa resthesias/tingli
ng /
swe l
li
ng? • Doy o
uc onsumea l
cohol?Dur at
ion&
• Anywe aknesso rmus clepa i
n? frequency
.
• Istherea nya ssocia tedpa i
n? • Anyf amilyhist
oryofthyroiddis
e ase
?
• Anydi ff
icultyo pe ningjars/t
urningk eys
? • Anyf amilyhist
oryofcanc e
rs/me dic
al
• Anys y mpt omsi nni ghtt i
me ? ill
ness
e s
?
• Anya b no rma lpo siti
ono ftheha nd?
• Anyne ckpa in/uppe rarm we akness?
• Simi l
ars ympt omsi no therpartsofthebo dy
?
• Doy ours ympt omsbe c
o mec hangewi t
h
t
ime?
• Anyc ha ng esinv ision/speech/headache?
• Anyc ha ng esing a it?
• Oc cupa t
ion?

Di
ff
ere
nti
alDia
g nosi
s Ma
nage
me nt
• Ca rpa
lTunne lSyndro
me . • Mo dif
yma nualwork.
• Ce rvi
calradi
culo
pathy. • Wr i
stspl
int(of
tenwo r
na tnig
ht).
• TI A. • NSAI Ds,loc
alcort
icos
teroi
dinject
ions.
• Co ntrolunderl
yi
ngs ys
temiccontri
butor
s
I
nve
sti
gat
ions (e
.g.di
abetes
,hypothyr
oidis
m, a
rthri
tis
).
• CBC, bl
oodglucos
e,el
ect
rol
yte
s. • Sur gi
caldecompres
sionviafl
exor
• C- s
pineXr ay
. re
tinac
ulum rel
eas
e.
• Ne rv
ec onduc
tio
ns t
udi
es. • Or thopedicorPlas
tics
urgeryconsul
t.
>8 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

RuthGagno
n,a60year
sol
dwo manpr
esent
edtoyo
uro f
fi
cewit
hri
ghtsi
dedc
alfs
wel
li
ngf
ort
hepa
st2da
ys.
Takeafo
cus
edhis
tor
yandperf
ormfoc
usedexa
minat
ion.
Vit
als
:BP-140/
80mm Hg ,HR-86/min,RR-12/min,Temp-37.
5°C

Cli
nica
lInfo:MsRuthGa gnonishavi
ngrig
htcalfs
wel
li
ngandrednes
sforthepast2day
s.Shehasl
egpai
n
al
so.
Shei saknownhyper
tensi
veonme di
cat
ions
.Sherec
ent
lytr
avel
edfor20hoursinanoverni
ghtf
li
ght
.
Sheiscomplia
ntwit
hherme dic
ati
ons
.Shehaspasthi
st
oryofbr
eastc
ancert
reat
me nt5yearsagowi
thno
compli
cat
ions.
Cli
nica
lCa se:Dee
pVe i
nThr ombosi
s

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha v
edi abetesorhy pertension?
• Ho wdi ditstart?Sudde no rg r
adua l
. • Ar eyo uona nyme di c
ati
o ns ?
• Isitge tt
ingwo rse/be t
tero rnoc hang esi
n • Ar eyo ual
lergictoa nyme dicat
io ns?
t
hes y
mpt oms ? • Anys urg
eri
e sinthepa st?
• Dur ationo flegs we ll
ing ? • Pa s th/orecurrentinfect
ions ?
• Whe reisthel egs well
ingl ocat
ed?
• Anyl egpa i
na sso ciat
edwi t
hs we l
ling? Fa
mi l
yandSoc i
alHi st
ory
• Ty peo fpa i
n-s ha rpo rdullpain? • Doy ousmo k e
?Dur ati
on& f requenc y
.
• Do est hepa i
nr a diateo rshoota nywhe re
? • Doy oucons umea lcohol?Dur ation&
• Se ver
ityo fpaino nas c al
eo f1-10. frequency.
• Anypa indur ingr e s
t? • Anyf amil
yhi st
o r
yo fthyro iddise a
se?
• Anypa inint heni ghtt i
me ? • Doy outakea nyrecreati
o na ldrug s
?
• Anys k indisco l
o rati
o no flegs
/na i
lc hanges
? • Anyf amil
yhi st
o r
yo fcanc ers/me dic
a l
• Anys k inulceratio no flegs? ill
ne s
s?
• Anyf e ver/c
oug h/ cold?
• Anyc hestpain/s hortnesso fbreath?
• Anyhe ada c
he /diz zi
ne ss
?
• Anywe akness/mus cl
epa in?
• Anyr e centtravel?
• Anypr olongedi mmo bili
zatio
n?

Di
ff
ere
nti
alDiagnos
is Ma
nage
me nt
• De epVe i
nThrombos
is. • Ur gentme di
cinecons
ult.
• Rupt ur
edBa ke
r'
sCyst
. • Lo wmo le
cul
a rwei
ghthepari
nx3days
.
• Ce ll
uli
ti
s. • The nswit
chtoWa rfa
rin.
• Uni l
ater
ally
mphede
ma . • I VCf il
ter
s(onlyi
fanti
coagul
ati
oni
s
contra
dict
ed)
.
I
nve
sti
gati
ons
• CBC, ESR, Lipidprof
il
e,RFTs.
• D- dimer.
• PT, PTT, INR, fact
orass
ay.
• De fi
cie
ncyo fAnt it
hro
mbi nII
I,pr
ote
inCo
r
S.
• Lupusa nti
coag ula
nt.
• Do ppleroflowe rl
imbs.
• I mpedanc
epl ethysmogra
phy.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
✏⌥⌅
⇡✓⌅
) ⌦
⌦ ⌦>'

MathewHobbs,
a55year
sol
dma npr
ese
ntedwit
hnumb nes
sinhi
sbot
hfeet
.Hei
sak
nowndi
abe
tic
.Ta
kea
f
ocusedhi
st
orya
ndper
formfoc
use
dphysi
cale
xamina
tio
n.
Vi
tals
:BP-130/90mm Hg,
HR–86/ min,RR–14/min,Temp–38.
5°C.

Cli
nic
alInf
o:MrMa t
hewHobbsisak
nowndia
beti
cfo
rthepas
t15ye
ars
.Heiso
nor
alhy
pog
lyc
emi
cs.
His
l
astf
ast
inggl
ucos
ewas7.6mmol
/L.Onex
amina
tio
n,bot
hfee
twe r
eno
rmal.
Cli
nic
alCase:Dia
bet
icFoot

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy o
uha vedi abeteso rhy perte
nsio
n?
• Ho wdi dnumb ne ssstart?Sudde no r • Ar eyouona nyme di cati
ons ?
g
radua l. • Ar eyoualler
g i
ct oa nyme dicat
ions?
• Isitge tt
ingwo rse/be tt
ero rnoc hang e
sin • Anys urgeri
esi nthepa st
?
t
hes y
mpt o ms ? • Pa sth/orecurrenti nfectio
ns ?
• Dur ationo fnumbne ss?
• Lo cat
io no fnumb ne ss? Fa
mi l
yandSoc i
alHi story
• Istherea nypa ina sso ciat
edwi thnumb nes
s? • Doy o
us mo ke?Dur ationa ndfrequency.
• Ty peo fpa in-s harpo rdullpa i
n? • Doy o
uc onsumea lcoho l
?I fyes,dur
ation,
• Do est hepa i
nr a di
a teo rshoota nywhe r
e? amo untandf requenc y.
• Se ver
ityo fpa i
no nas cal
eo f1-10. • Doy o
uus erec r
ea t
iona ldrug s
?TRAPPED
• Doy ours ympt omsc ha ngewi thti
me ? • Anyf amilyhistoryo fc ancers/medic
a l
• H/ oting l
ing ? ill
ness
es?
• Anyr e centi njuryt of eet? • Ex er
cis
esche dule.
• Anybl is
ters /
c al
luseso nthef e
e t? • Di et
aryrest
ricti
o nsfo rdiabe t
es.
• Anys we llingo ffeet? • Co mplia
nc ewi thme dicat
io ns
?
• Anyc hang esi nv isi
o n?
• H/ odi zzine ss/LOC?
• H/ oc hestpa i
n/ ortho pnea?
• H/ oe xcessives we ating ?
• Anyc hang esi na ppe tit
e ?
• Anyc hang esi nwe ight?
• Anyc hang esi nbo we l& ur i
naryha bit
s?
• La stf
a st
ingbl oo ds ug ar
,eyea ndfoo texa
m?

Di
agnos
is Ma
nage
ment
• Di abe
ticf
oot • Selffootexam da i
ly.
• Foo texaminedr egula
rlyatphysi
ci
anvis
it
s.
I
nve
sti
gat
ions • Perform Peri
phe ra
lNe uropathyTes
ti
ng.
• Fa s
ti
ngbloodgluc
ose
. • Che ckforpeda lpulses
.
• HbA1C. • Eva l
uate& agg res
sivel
ytreatnewfoot
• Fa s
ti
ngli
pids. wo
und.
• ECG. • Avo idfoottr
auma
• Fundo scopy
. • Dono twalkba ref
o ot
.
• Ur i
nal
ysi
swithuri
nedip
. • Cutna il
sc ar
efull
y.
• Avo idexces
sivehea torchemical
s.
>9 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

WayneSing
er,
68yea
roldmanpr
ese
nte
dwi t
hdi
ff
ic
ult
yswa
ll
owi
ngf
ort
hepa
st4mo
nths
.Ta
keaf
ocus
ed
hi
st
oryandper
for
m afo
cus
edexa
minat
ion.

Cli
nic
alInf
o:MrWa yneSingerhasdif
fic
ult
ys wal
lowi
ngf o
rthepast4mo nt
hs.
Itha
sgr
adual
lyinc
rea
sed
f
romsoli
dstol
iqui
ds.Hef e
elsalumpi nthethroat
.Heha sche
stpai
nwhe nheeat
sfo
od.
Heha snoti
ced
wei
ghtlo
ss,
nig
htsweatsanddec r
ease
da ppet
iteinthel
ast3mo nt
hs.Heisachro
nics
mokerf
orthepast30
ye
ars
.
Cli
nic
alCase:
Di f
fi
cultySwall
owing(CaOe sophagus
)

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy o
uha vediabet
esorhy pert
e nsion?
• Ho wdi di tstart
?Sudde no rg r adual. • Ar eyouo nanyme dic
ati
o ns?
• I si tgetti
ngwo r
se/bettero rnoc hang esin • Ar eyoualle
rgictoanyme dicat
io ns?
thes ympto ms ? • Anys urgeri
esinthepast?
• Dur ati
ono fdiff
icultyswa ll
o wi ng? • Anyhi stor
yo fgoit
reorthyroidpr oblems?
• I st heredifficult
yt ransferringf oodf rom • Anyr adiat
ione x
posur
e?
mo uthtoe so
pha gus( sug gestiveo f
oro pha r
yng ealdyspha gia )o rfur therdo wn Fa mi l
yandSoc ial
Hi st
ory
(sug gest
iveo fe s
opha g ealdy spha gi
a )
? • Doy o
us mo ke?Durati
on& f reque ncy.
• I st hepr oblem wo rsewi ths olids( s
ug gest
s • Doy o
uc onsumea l
cohol?Dur ation&
me chanicalobs t
ruct i
on)o rliqui ds( s
ug ge
sts frequency
.
ne uromus culardy sfunctio n,o ftenc an'
t • Anyf amilyhisto
ryofthyroiddise ase
?
swa llowbo t
hs oli
dsa ndl iquids )? • Anyf amilyhisto
ryofcanc e
rs/me dic
al
• I st hereas ens a
tiono flumpi nt hethro a
t ill
ness
e s
?
(glo bushy ste
r i
cus)?
• Pr o g r
essi
o no fswa l
lowi ngs olidsdi ff
icul
tyto
difficult
yi nswa ll
o wingl iqui d?( Sug gest
sa
wo rs e
nings trict
ureo fg ro wingt umo r)
• Anys we l
lingt hene ck ?
• Ag gravat
ing ,rel
ievingf acto rs?The
asso ci
ationo fintermi tt
e nto bs tructionand
che stpains ug ges
tse sopha geals pasm.
• H/ O pe pticul cer
,re f
lux, hiatushe rnia
?
• H/ Of ever,nightswe a t
s, we ightl oss,f
a t
igue
,
he ma teme sis
,blacks tools?

Di
ff
ere
ntia
lDi agnos i
s • Ches
tX- r
ay.
• Es ophagealCa ncer
. • LFTs,RFTs.
• St rict
ureduet oGERD/ Trauma. • Abdominalul
tr
aso
und.
• Ne uromusc ula
ro b
struct
ion–a chal
asi
a, • CBC.
c
ranialner
v epalsy
,MS, supranucl
earpal
sy
, •
s
troke,moto rneur
ondi s
e a
se,my a
sthe
nia • Manage
me nt
g
ravis
, musculardyst
rophy. • Ur
gentsur
gic
alc
ons
ult
.

I
nve
sti
gat
ions
• Endo s
copywithbiops
y.
• Uppe rGIs eri
es.
• CTc hest(f
orme di
ast
ina
landl
ymphno
de
i
nvol
vement)
.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
✏⌥⌅
⇡✓⌅
) ⌦
⌦ ⌦>=

Bra
dChisol
m, a35ye
arsol
dma npre
sent
edwit
hbloodyvomit
ingt
otheERf
ort
hepa
st2ho
urs
.Ta
kea
f
ocuse
dhis
toryandper
for
mf o
cusedphys
ica
lex
amina
tion.
Vi
tal
s:BP-90/60mm Hg ,HR-116/min,RR-12/min,Temp-37.
0°C

Cli
nicalInfo:MrBr adChisol
m present
edwi t
ha c
uteonseto
fbloodinvomit
us,2e pi
sodesin2ho ursag
o.
Heha snohi st
oryoftrauma.Nona l
cohol
ic,nonsmoker.
Heha sbeenhavi
ngchronickneepa i
na f
tera
s
kateboar
dinga cc
ident2we eksag
o.Hei sta
k i
ngIbuprof
enforthepast2weeks4-5ti
me sada y.
Ha s
moderat
ee pigas
tri
cpain.Nohe moptysi
s,he
ma tur
iaorhematoc
hezia
.Nos ur
geri
es/medicalil
lnes
ses.
Cli
nicalCas e:Hema t
eme s
is

HOPI Pa
stHis
tor
y
• OCD PQRSTUVW +AAA • Doy o
uha v
emedi
cali
ll
nes
ses
?
• Ho wdi dits tart
?Sudde no rgradual
. • Anysurg
eri
esi
nthepas
t?
• Isitg etti
ngwo r
se /
be ttero rnoc hangesin
t
hes ympt o ms ? Fa
mi l
yandSoc ial
Hi st
ory
• Dur ationo fbloo dinv o mi tus
? • Doy o
us mo ke
?Dur at
ion& fre
quency
.
• Amo unto fblood? • Doy o
uc onsumea l
cohol
?Dur a
tio
n&
• Co loro fblo od? fr
e quency
.
• Numbe rofe pisodes ? • Anyf amilyhist
oryofcance
rs/medic
al
• Istherea nya bdo mina lpa in? • Doy o
ut akeanyrecr
eat
ionaldr
ugs?
• Ty peo fpa in-s ha r
po rdul lpa i
n? • Anyf amilyhist
oryofcance
rs/medic
al
• Do est hepa i
nr adiateo rs ho o
ta nywhere? il
lness
e s
?
• Se ver
ityo fpa ino nas caleo f1-10.
• Doy ours ympt o
msc hang ewi thtime?
• Anybl oodwhi lec oug hing ?
• Anybl oodi ns too l
s/lastbo we lmov e
me nt
?
• Anybl oodi nur ine?
• Anyt r aumat oa bdo me n?
• Anyf e verr ecently?
• Anydi zzine s
s/fainting?
• Cur rentlyo na nyme dicat
io ns?
• La stme al?
• Anya ll
e r
g i
cr eactions ?

Di
ff
ere
nti
alDiagnosi
s Ma
nage
me nt
• Ga str
iculce
r. • ABC.
• Ac uteEsophagi
ti
s. • Admi t.
• Ac utegast
ri
tis
. • NPO.
• Dr uginducedcoag
ulo
pat
hy. • NG t ube.
• I VFvial
argeborecannul
as.
I
nve
sti
gat
ions • I njRani
ti
dine50mgI Vbo l
usandq8h.
• CBC, elec
tro
lyt
es,
g l
uco
se. • I ncas
eofpe r
for
ate
dul c
er-sur
geryco
nsul
t.
• LFTs ,RFTs.
• PT, PTT, INR.
• Bl oodg r
oup& cros
sma t
ch.
• Ur gentendosco
py.
• Upr i
g htabdominalXRa y
.
0- ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

MaryLapl
ant
e,a40year
soldla
dypres
entedwithswe
ll
inginthene
ckfort
hepa
st1mo
nth.
Tak
eaf
ocus
ed
hi
st
oryandpe
rformfo
cusedphys
ica
lexaminat
ion.
Vi
tal
s:BP-120/88mm Hg ,
HR–96/ mi n,RR–12/min,Temp–37.5°
C.

Cli
nic
ali
nfo:MsMa ryLapla
ntenot
ic
edt hi
sswel
li
ngint
hea
nter
iorneckwi
th noot
herpr
ominent
s
ymptoms.One x
aminat
ion,t
her
eis2cm x2cm mobi
le
,nont
enderthy
roide
nla
rgeme
ntinthel
eftl
obe
.
Cli
nic
alCase:NeckSwel
ling

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy o
uha vedia bet
esorhy per
tension?
• Ho wdi ditstart?Sudde no rg r
adua l
. • Ar eyouona nyme dic
ati
o ns?
• Isitg ett
ingwo rse/bet t
e ro rnoc hangesin • Ar eyouall
ergict oanyme dica
tions?
t
hes ympt oms ? • Anys urger
iesint hepast?
• Sinc eho wlo ngha v ey ouno ti
cedthel ump? • Anyhi st
oryo fg oit
reorthyroi
dpr oble
ms ?
• Whe reisthel umpl o cated? • Anyr adi
atione xposur
e?
• Ho wdo esthel umpf eellike?
• Isthe r
ea nypa i
na sso ciatedwi t
ht helump? Fami l
yandSoc i
alHi st
or y
• Ty peo fpa i
n-s harpo rdul lpain? • Doy o
usmo k e?Dur ati
ona ndfrequency.
• Do est hepa inra di
a teo rs hoota ny
whe re? • Doy o
uc onsumea l
cohol?Ifyes
,dur at
ion,
• Se veri
tyo fpa i
no nas caleo f1-10. amo untandf r
e quency.
• Doy ours ympt omsc ha ng ewi t
ht i
me ? • Anyf amil
yhi storyofthyroiddis
e a
se?
• H/ of ever/c
o ugh/ s
o ret hro at
? • Anyf amil
yhi storyofcanc e
rs/
me dical
• Anywe aknesso rmy algia? ill
ness
es?
• Anyc hang einv o i
ce?
• Anyc hang einv isi
o n?
• Anyc hang eina ppe tite?
• Anyc hang einwe ight ?
• Anyc hang esinbo we l& ur i
naryha bi
ts?
• Anyt empe ratureint oleranc e?
• Anypa lpita
tionso rt remo rs?
• Anys we l
li
ngo ffaceo rfee t?
• La stme nstrualpe riod?
• Anyc hang esinme ns trualc ycl
es?

Di
ff
ere
nti
alDiagnosis I
nve
sti
gat
ions
• To xicnodulargoi
tr
e. • TSH.
• Ha s
himo t
o'sthy
roi
diti
s. • Fr eeT3a ndT4.
• Thy roidcyst. • Thy r
oidult
ras
ound.
• Thy roidadenoma. • Thy r
oidbiops
y.
• Thy roidlymphoma . • Ant i
micr
o s
omal& a
nti
-t
hyr
ogl
obul
ina
bs.
⇥ ◆
⌦◆⇢
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/⌦
✏⌥⌅
⇡✓⌅
) ⌦
⌦ ⌦0

J
udyFra
nce
s,a25ye
arol
dfemal
epre
sent
edtoyo
uroff
ic
ewi
thl
owe
rabdo
mina
lpa
inf
ort
hepa
st1da
y.Ta
ke
af
ocus
edhi
stor
yandpe
rfo
rm af
ocus
edexami
nat
ion.

Cli
nic
alInfo:MsJ udyFra
nceshadag r
adualonse
tofri
ghtl
owe rabdominalpa
in24hoursago.Thepai
nhas
gra
dual
lyincrea
sedinint
ensi
ty
,grade7/10.
Sheha sf
eve
r,na
useaandv omit
ingsi
ncemorning.Nobowelor
uri
nar
ycompl ai
nts.Notr
auma .
He rLMPwa soneweekago.
O/ Epe r
it
o ne
alsi
gnsar
epresentandte
nder
ness
atMcBurney'spoi
nt.
Cli
nic
alCa se:Pai
nAbdome n/ AcuteAbdome n

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy o
uha vediabet
esorhy pert
ension?
• Ho wdi di tstar
t?Sudde norg radua l
. • Ar eyouo nanyme dic
ati
o ns?
• Isitge t
t i
ngwo rse/be tt
ero rnoc hangesin • Ar eyoualle
rgictoanyme dicat
ions?
t
hes y
mpt o ms? • Anys urgeri
esinthepast?
• Dur ationo fabdo mi nalpain?
• Whe reist hepa inl oc a
ted? Fa
mi l
yandSoc ial
Hi st
ory
• Ty peo fpa in-s ha rpo rdull? • Doy o
us mo ke
?Dur ati
on& f re
que ncy
.
• Do esthepa i
nr adiateo rsho otany where? • Doy o
uc onsumea l
cohol?Dur at
ion&
• Se ver
ityo fpa ino nas cal
eo f1- 10. frequency
.
• Doy ours ympt omsc hangewi tht ime? • Doy o
uus erecre
ati
onaldrugs?TRAPPED.
• Anya gg ravat
ingo rre l
ievi
ngf acto r
s(change • Anyf amilyhist
oryofcanc e
rs/me dic
al
i
npo si
tio n/foodi ntak e)
? ill
ness
e s
?
• Ef f
ecto na ct
ivi
tieso fda i
lyliving ,f
uncti
onal
l
imita
tio n?
• H/ ofev er,nausea /vomi ti
ng, di
z zines
s/fa
int
?
• Anyur ina rycompl aints?
• Lo oses tools/blacks t o
o l
so rbloo dinstool
s?
• Cha ng eins t
oolc ali
be r?
• Fe males:
LMP?
Paina ssociatedwi t
hpe riods?
Vagina ldischarg e?

Di
ff
ere
nti
alDi a
gnosis Ma
nage
me nt
• Appe ndic
iti
s. • Admi t.
• UTI . • Ur ge
nts ur
gic
alcons
ult
ati
on.
• Re nalc o
licduetone phr
oli
thi
asi
s. • I VF.
• PI D. • I VAntibiot
ic
s.
• Ec topicpregnancy. • NPO, NG tube.
• Rupt uredOv aria
nc ysto
rov a
ria
ntor
si
on.
• Mi t
tels
chme rzsyndr
o me.

I
nve
sti
gat
ions
• Abdo minalX- r
ay3v ie
ws
• Abdo minal& pelvi
cultraso
und
• CBC, Elect
rol
ytes,
Ur ea
,Cr e
ati
nine
• I NR/ PTT, Glucose,be
taHCG
• Ur i
nalysi
s
• St oolforoccul
tblood
• Ce rv
icalswabsforcult
ure/PAPs mear
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⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Ronal
dMa ndel
,a65ye
arsol
dma npre
sente
dtoy ouro
ffi
cewi
thbi
la
ter
all
egpa
inf
ort
hepa
st2we
eks
.Ta
ke
af
o c
usedhi
sto
ryandper
for
mf o
cusedexamina
tio
n.
Vi
tals
:BP-140/90mm Hg,HR-86/ min,RR-12/ min,
Temp-37.5°
C

Cli
nicalInf
o:MrRo nal
dMa nde lisaknownhy pe
rte
nsi
vefo
r15yea
rs.
Hewa sdia
gnose
dwithCAD 5y e
ars
ag
o .
Hei shavingbil
ate
rallo
we rlegpa i
nfort
hepast2weeks
.Pai
nst
art
so nl
ywhe nhehaswal
kedfo
r10-15
minute
s.Painsubsi
desaft
ertakingr e
st.Hehaspar
est
hes
iast
oo.
Nowe aknes
so rni
ghtpai
n.Heisachr
onic
s
mo keranda l
cohol
icfor20years.
Cli
nicalCase:Peri
pheralVasc
ul arDiseas
e

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha v
edi abetesorhy pertension?
• Ho wdi dits t
art?Sudde norg r
adua l. • Ar eyo uona nyme di c
ati
o ns ?
• Isitg ett
ingwo rse/bettero rnoc hangesin • Ar eyo ual
lergictoa nyme dicat
io ns?
t
hes ympt oms ? • Anys urg
eri
e sinthepa st?
• Dur at i
ono flegpa i
n? • Pa s th/orecurrentinfect
ions ?
• Whe reisthel egpa inlo ca
ted?
• Ty peo fpa i
n-s ha r
po rdullpain? Fa
mi l
yandSoc i
alHi st
ory
• Do est hepa inr adiateo rshoota nywhe r
e? • Doy ousmo k e
?Dur ati
on& f requenc y
.
• Se verit
yo fpa i
no nas c al
eo f1-10. • Doy oucons umea lcohol?Dur ation&
• Di st
a nceo rti
mewa lke dbe f
orepa insta
rts
. frequency.
• Spe edo fwa lkingbe f
o repainstarts. • Anyf amil
yhi st
o r
yo fthyro iddise a
se?
• De gre eofinclinewa lked. • Doy outakea nyrecreati
o na ldrug s
?
• Anypa i
ndur ingr est? • Anyf amil
yhi st
o r
yo fcanc ers/me dic
a l
• Anypa i
nint heni ghtt i
me ? ill
ne s
ses?
• Anys kindi sc
o lorati
o no flegs
/na i
lchanges?
• Anys kinul ce
ra t
io no flegs?
• Anyc hestpa i
n/s hortne s
so fbreath?
• Anyhe a
da che/diz z
ine ss?
• Anywe akness/mus clepa in?
• Dot hes ympt omsc omeba ckwi the x
erti
on?
• H/ oi mpo tence?

Di
ff
ere
nti
alDiagnosi
s Ma
nage
ment
• Pe ri
pheralVasc
ula
rDisea
se. • Sympt omati
ctre
atment.
• Os teoa
rthrit
is
. • TabAs pir
in75-150mgOD.
• Ne urogeni
cc l
audi
cat
ion. • Clopidogre
l.
• Ba ker'
scyst. • Vascula
rsurger
yo pi
nio
n.
• Reduc t
ionofCAD r i
skfac
tor
s.
I
nve
sti
gat
ions • Alcohol& smokingcess
ati
on.
• CBC, Lipidprofi
le
.
• Se r
um Ho mocyst
eine,Apo l
ipopro
tei
nA.
• Se r
um Cr eat
ini
ne.
• He mo gl
o bi
nA1C, fa
stingglucose
.
• Ur i
nalys
is.
• Ank lebrachi
alindex,Do ppl
e rofl
ower
l
imbs.
• CTAng io gr
aphy.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
✏⌥⌅
⇡✓⌅
) ⌦
⌦ ⌦0%

Al
exPerei
ra,
a45yea
rsol
dma npre
sent
edwithhighgr
adefeve
rwit
hchil
lso
nda
y3a
fte
rhi
sabdo
mina
l
s
urg
ery.Ta
keafoc
usedhi
st
oryandperf
ormfocus
edphysi
calex
ami
nati
on.
Vi
tal
s:BP-110/
80mm Hg ,HR-96/ min,
RR-12/ min,
Te mp–38.
5°C.

Cli
nica
lInfo:MrAl exPer
eir
awa soperat
ed3da y
sa gofo
ra c
utea ppendi
cit
is
.Themorni
ngshif
tnurs
e
not
ice
dt emperat
ureof39.
8ºC. Hei scompl
aini
ngo fchi
ll
s,ri
go rsandnausea.
Hehaspai
natthewoundsit
e.
Noburninginurine.Hadonebowe lmovementinthemo rni
ng. Noc hes
tpainors
hor
tne
ssofbrea
th.I
V
ant
ibi
oti
cswe r
estoppedonpostopda y2.Noo t
hercomplica
tio
ns .O/E:Wo undsi
tei
ste
nder,
eryt
hemato
us
wit
hyell
owishdischar
ge.
Cli
nica
lCa se:PostOpera
tiv
efeverseconda
rytowoundi nfe
ction

HOPI Pa
stHistory
• OCD PQRSTUVW +AAA • Doy ouha v
edi abetesorhy pert
ension?
• Ho wdi ditsta r
t?Sudde no rgra
dual. • Ar eyo ual
lergictoa nyme dicat
ions?
• As s
ociate
dwi tha nyc hi
lls/r
igor
s? • Anys urg
eri
e sinthepa st
?
• Dur at
iono ffe ve
r ? • Pa s th/orecurrentinfec
tio
ns ?
• Feverpa t
tern-c ontinuous ,i
nte
rmitte
nt,
r
emitt
ent? Fa
mi l
yandSoc i
alHi st
ory
• H/ ocough/ sorethro at/
rash? • Doy ousmo k e
?Dur at
ion& f re
que ncy
.
• Anyc hestpa in/shortnesso fbr
eath? • Doy oucons umea lcohol
?Dur at
ion&
• Anya bdo mina lpa i
n? frequency.
• Anybur ningi nur ine/cloudyurine? • Doy outakea nyrecreat
iona ldr
ug s?
• Anydy suria/hema t
uria? • Anyf amil
yhi st
o r
yo fcancers/me dic
al
• La s
tbo welmov eme nt? ill
ne s
ses?
• Anypa ina tthewo unds ite?
• Whe nwa sthewo unddr e ss
ingchanged?
• Anypa ina ttheI Vs ite?
• Anypa ininc a l
ves?
• Anyl egswe ll
ing?
• Cur r
entlistofme dicati
ons ?
• Anyc hang esinme dicati
o ns?
• La s
tme al?
• Re a
sonf orsur gery?
• Anypr e-op/intra-ops urgicalco
mpl i
cati
ons
?

Di
ff
ere
nti
alDiagnosis Ma
nage
ment
• Po stopwo undi nf
ect
ion. • StartIVAnt i
bioti
cs& Anti
pyr
eti
cs.
• Ur ina
ryt r
actinfec
ti
on. • Wo unddr a
ina g
e.
• I nt
ra-abdominalabsce
ss. • Wo unddr e
ssingforhea
li
ngby
• Se pti
cthrombo phle
bit
is. se
condaryintenti
on.
• Vitalsq4
ht i
llfeve
rsubsi
des
.
I
nve
sti
gat
ions
• CBC, ele c
trol
yte
s,glucos
e.
• LFTs ,RFTs .
• Ur i
nero uti
neandc ult
ure/
sens
iti
vi
ty
.
• Wo unds wa b,
cult
ure/se
nsit
ivi
ty
,gra
mst
ain.
• Bl oodc ult
ure/s
ensi
tivi
ty.
• Ul t
ras
ounda bdome n.
0> ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Di
aneRi c
hards
on,a55y
ear
sol
dwo manpr
esent
edwit
hinci
dent
alf
indi
ngofl
ungno
dul
eonc
hes
txr
ay.
Tak
e
af
ocusedhis
tor
yandper
for
mfocus
edphys
ica
lexami
nati
on.
Vi
tal
s:BP-120/80mm Hg,HR-86/min,RR-18/min,Te
mp–37. 5°
C.

Cli
nic
alInfo:MsDi aneRi c
hards
o nhaschr
oniccoughfor2mont
hs.
Itwasgradua
linonse
t.Nofeve
ror
r
ecur
rentpneumonia.Ar outi
nechestXrayrev
ealedsol
it
aryno
dul
einther
ightmiddlel
obe.Shei
sakno
wn
s
mo ke
rforthepast30y ea
rs.Sheisachro
nical
c o
ho l
ica
lso.
Cli
nic
alCa se:
Solit
arylungnodule

HOPI Pa
stHis
tor
y
• Whywa sthec he stXr aydo ne? • Doy ouha vedia
bet
eso rhyper
tensi
on?
• OCD PQRSTUVW +AAA • Areyo uona nymedica
tions?
• Ho wdi dc oug hsta r
t?Sudde norgradual
. • Co mplia
ncewi t
hme di
c a
tio
ns?
• Isitg ett
ingwo rse/bett
ero rnoc ha
ng e
sin • Areyo uall
ergi
ctoanyme dica
tions
?
t
hes ympt oms ? • Anys urge
riesi
nthepast?
• Dur ationo fc oug h? • Pasth/orecurr
enti
nfecti
ons?
• Ty peo fc ough–dr y
/expec tor
ant?
• Amo unt/c oloro fcough? Fa
mi l
yandSoc ial
Hi st
ory
• Anyo fsho rtnesso fbreath? • Doy ousmok e
?Dur at
ion& frequency
.
• Pre s
enta tr es
to rwi thex erti
on? • Doy ouconsumea l
cohol
?Dur ati
on&
• H/ oo rthopne a? fr
e quency
.
• H/ opa ro x
y sma lno c
turnaldy spnea? • Anyf amilyhist
oryofcanc
e r
s/me dic
al
• Anyc hestpa in/pa l
pita
tions ? il
lnesses
?
• Do est hepa inr adiateors hootanywhe r
e? • Oc cupati
on?
• Se ver
ityo fpa ino nas caleo f1-10. • Ex posur
etoc ar
cinog
enicsubst
ances?
• Doy ours ympt o msc hang ewi t
ht i
me ?
• H/ ofe ver/chil
ls/nightswe a t
s?
• Anyc hang einwe ight/appe t
ite
?
• Anyr e centt r
a vel
?
• Anyc ontac twiths ickpe r
s on?
• Anype tsa tho me ?

Di
ff
ere
nti
alDiagnosi
s Ma
nage
ment
• LungCa rci
noma. • Sympto mati
ctre
atment.
• So li
tar
yg r
anulo
ma . • Compa ris
onwitholderchestXr
ays
.
• Pul monarytuber
cul
osi
s. • Urgentrespi
rol
ogyconsult
.
• TBs kintest
.
I
nve
sti
gat
ions • CTg uidedbiopsy
.
• CBC, el
ectr
oly
tes
,gl
uco
se. • Bronchoscopy
.
• LFTs ,
RFTs .
• Che s
tXRa y.
• CTChe s
t.
• Sput um c
ytol
ogy.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
✏⌥⌅
⇡✓⌅
) ⌦
⌦ ⌦00

El
aineJo
nes
,a60y e
arsol
dla
dypres
ent
edwi t
hswel
li
nginthene
ckfo
rthepa
st4mo
nths
.Ta
keaf
ocus
ed
hi
st
o r
yandper
formfocus
edphy
sic
alex
aminati
on.
Vi
tals
:BP-120/80mm Hg ,
HR–88/ min,RR–12/min,Temp–37.
5°C.

Cli
nica
linf
o:MsEl a
ineJonespres
ente
dwi t
hasoli
tar
yswelli
ngintheri
ghtlo
beofthet
hyro
idforthepa
st4
months.
Thes we
ll
ingha si
ncrea
sedinsi
ze.Shehasnofeve
r,coug
ho rso
rethr
oat
.Shehasde
cre
asedappet
it
e
and5kgwe i
ghtl
ossinthepast3mo nt
hs.Shehashoar
senes
so fv
oice
.
Cli
nica
lCase:Thyroidma s
s

HOPI Pa
stHis
tor
y
• OCD PQRSTUVW +AAA • Doy o
uha vediabet
esorhy per
tensi
on?
• Ho wdi ditstart?Sudde no rg r
adua l
. • Areyouona nyme dic
ati
ons ?
• Isitge tt
ingwo rse/bet t
e ro rnoc hangesin • Areyouall
ergictoanyme dica
tions
?
t
hes y
mpt oms ? • Anysurge
riesinthepast
?
• Sinceho wlo ngha v ey ouno ti
cedthe • Anyhist
oryo fgoit
reorthyroi
dpr o
ble
ms?
s
we l
li
ng ? • Anyradi
ati
o nexposur
e?
• Whe reisthes we l
li
ngl oca t
ed?
• Ho wdo esthes welli
ngf eellike? Fa
mi l
yandSoc ial
Hi st
ory
• Istherea nypa i
na sso ciatedwi t
ht he • Doy o
us mok e
?Dur at
ion& fre
quency.
s
we l
li
ng ? • Doy o
uc onsumea l
cohol
?Dur a
tio
n&
• Ty peo fpa i
n-s harpo rdul lpain? fr
e quency
.
• Do est hepa inr adi
a teo rs hoota ny
whe re? • Anyf amilyhist
oryofthyr
oiddis
ease
?
• Se ver
ityo fpa i
no nas caleo f1-10. • Anyf amilyhist
oryofcanc
ers/medic
al
• Doy ours ympt omsc ha ng ewi t
ht i
me ? il
lness
e s
?
• H/ ofe ver/c
o ugh/ s
o ret hro at
?
• Anywe aknesso rmy algia?
• Anyc hang einv o i
ce?
• Anyc hang einv isi
o n?
• Anyc hang eina ppe tite?
• Anyc hang einwe ight ?
• Anyc hang esinbo we l& ur i
naryha bi
ts?
• Anyt e mpe ratureint oleranc e?
• Anypa lpita
tionso rt remo rs?
• Anys we l
li
ngo ffaceo rfee t?

Di
ff
ere
nti
alDiagnosis Ma
nage
me nt
• Thy roidadenoma . • Urg e
nts urgi
calopini
on.
• Mul ti
no dulargoi
tr
e. • Radioiodineinc a
seofhyper
thyr
oidi
sm
• Thy roidcyst. • Che mo/r a
diot
he r
apyincas
eo fa
napl
ast
ic
• Pa ra
thyroidadenoma. tumo r
.
• Be nignno dule
. • Surgica
lr emovalincase
sot
he rt
han
anaplas
tictumo rorlympho
ma .
I
nve
sti
gat
ions
• TSH.
• Fr eeT3a ndT4.
• Ra dio
acti
vethyroi
duptakesc
an-
Hotnodule:Hy po/
Hy pe
rthyroi
dis
m.
Coldnodule
:Thy r
oidmali
g na
ncy.
• Thy roi
dultr
asound.
• Thy roi
dbiopsyandc y
tol
ogy.
• Ne ckCT.
08 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

J
osephQuinto
n,a25year
soldmalewasbr
oug
htt
otheERaft
eramotorve
hic
leacci
dentwi
tht
hef
oll
owi
ng
v
ita
ls:BP-80/50mm Hg,HR-116/ min,
RR-10/mi
n,Te
mp-37.0°
C, O2sat-80%.
Managethepat
ientwi
thanurs
e.

Cli
nicalInfo:MrJose
phQui ntonhadaMVA1ho urago.
Heisconsci
ous,a
ler
tandr
espondingtov
erba
l
comma nds.Heisi
ne x
cruc
iat
ingpain& compl
ainsofdi
ff
ic
ult
ybreat
hing.
Hec anmovealll
imbs.On
aus
cult
ation,t
her
earedecr
eas
e dbre
athso
undsonr i
ghts
ideofche
stwithdul
lnes
sonperc
ussi
o n.
Diagnosis
: Tr
auma-Rightsi
de dhemot
horax.

• Introduc eyo urself.

• Ca llo utt hepa tient 'sna mea nda ssessv erbalre spons e.
• Follo wuni versalpr ecautio ns-ma s k,wa shha nds ,we arg l
ov es.
• As kf orpa t
ient '
sv itals.
• As kt hepa ti
entt obec onne c tedt omo nitors:ca r
diacmo ni t
or,BPc uff,pul s
eo xi
me ter, t
emperature
probe .
• Plac ec ervicalc oll
a rwi t
hi n- linet ra cti
o n.
• AI RWAY-Ope nmo uth& c he cka i
rwa yf ora nyl oosebo dy/dentur es/bleeding.Me ntionany
spec i
fics me ll
.
• BREATHI NG -
-LOOK-c ya no sis/
pa llor/icter us/na salfl
aring /che s
tmov ement s/respirat
o r
yra te/neckvenous
eng orgeme nt.
-FEEL-f lowo fa i
r/tra che als hift/chestwa l
lfo rc r
epi tus/f
lai
ls eg me nts/
suckingc hest
wo unds /subc uta neo use mphy se ma .
-LI STEN -s o undso fo bs truc tion/br eat
hs o unds /symme tryofa irent ry
/airescaping /
noisy
br eathing .
• CI RCULATI ON -f e elfo rpe riphe r
alpul ses/a ssessfo rs hock-capillaryr ef
ill
,coolex tre
me i
tie
s.
• DI SABI LITY-GCS/ pupi ll
a ryr eaction.
• Or de rpr ima ryI NVESTI GATI ONS-CBC, dif
fere ntials,el
ectr
o lytes,RFTs ,LFTs ,ABG, INR,
PTT, 12l eadECG, ur i
na lysis,ur inet ox i
co l
ogys creen,po r t
ableche stXr a y
,C- s
pineXr ay
,Blood
group , t
y pe& c ros sma tch, blo odg luco se.
• Plac elar geb oreI Vc a nnul asbo tha rms& I VF1lno rma lsali
nebo lussta t.
• Atta cht o100%o x yge nt hro ug hma sk/na sa
lca nnul as.
• As kf orv ital
sa g ain.
• As kf oro r
einta t
io nt ot ime /place/ pe r
so n,me cha nismo finj ury/anye yewi t
nesses
/a nyl ossof
cons cious ness/v omi ti
ng /pa ina ny whe reint hebo dy/l astme al
/anydr uga l
lergi
es/TAMPLEo r
SAMPLE.
• EXPOSURE/SECONDARYSURVEY-As sessf or:
-Sk ull/
c r
a nium f racture s.
-I njur i
est ot hef a ce.
-He mpt ympa num/o torrhe a/r hino rrhea/e pistaxis/ba tt
le'
ssign/r acoone yes
.
-Che ckuppe re x tremi tiesfo rf racture s
/br uises/la c
e rations/tatto os
/ne e
dletrackma r
ks/me di
c
alertbr acelet /sc ars/wo unds .
-Che cka bdo me nf o rmov e me nt s/s cars
/wo unds /br ui se
s/rigidity/ma sses
,bo we lsounds.
-Che cklo we re xtremi t i
e sfo rf ractures/brui ses/wo unds /tatt
oo s/ne e dl
et ra
ckma rks
.
-Pe lv i
cc ompr e ssi
o nt or ul eo utpe lvicfracture.
-De e ptendo nr e f
lex eso fuppe r& l owe rex tremi ti
es.
-Se ns orye x ami na ti
o no fuppe r& l owe rex tre
mi ties.
-Mo tore xami nationo fuppe r& l o we rextremi ties.
-Ge ni t
ale xami na ti
o n.
-Spi nale xami na tion-l o gr ollwi thhe lptol oo kfo rfra ct
ure/ste pde fo r
mi ty
.
-Di gitalrecta le xami na tion.
-Cha nger igidbo a r
dt os emir ig i
dbo ard.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦
✏⌥⌅
⇡✓⌅
) ⌦
⌦ ⌦0'

• Gi
veSECONDARYORDERS:
-Askforvitalsagai
n.
-Resul
tsoft heinves
tigat
ionorder
e dear
li
er.
-Requestforne edl
etho r
acos
tomywi th16G needl
ein2ndi
nte
rco
sta
lspa
ce.
-Askwha tdoy o use
e-a irorblo
od.
-Urgentcardio-thor
aciccons
ultforches
ttube.
-Order2Lbl oodtra
ns f
usi
on.
-Fo
le y
'scat
he ter
.
-Naso-gas
trictube.
-Me as
ureint a
ke/output.

Ma
nag
eme
ntf
ors
pec
ifi
ctr
aumac
ases
cena
rios

Ma
nag
eme
ntf orte
nsi
onpne umo t
hor
ax
• Lar
g eboreIVneedlein2ndint
erc
osta
lspac
ei nthemid-c
lav
icul
arli
ne.
• Cardio
- t
hora
cicc
o nsul
t.
• Chesttubetobeinsert
edint
he5thinte
rco
stalspac
eintheanter
iora
xil
la
ryl
ine
.

Ma
nag
eme
nto fopenpneumo thora
x
• 3si
deds eal
eddres
sing.
• Cardi
o -
thorac
icconsult
.
• Chesttubetobeinsert
edinthe5t
hint
erc
ost
als
pac
eint
hea
nte
rio
rax
il
la
ryl
ine
.

Ma
nag
ementoffla
ilchest
• Na s
aloxygen.
• IVflui
ds.
• PaincontrolwithInjMo rphi
ne2-
4mgI
V.
• Posit
ivepress
ureventil
ati
on.
• Ca r
dio-t
hor a
cicco
ns ul
t.

Ma
nag
ementofper
icar
dia
lt a
mpo na
de
• Na s
aloxyg
en.
• IVflui
ds.
• Ca r
dio-
thorac
icconsul
t.
• Peri
car
diocent
esi
s.

Ma
nag
emento fincr
ease
di ntracrania
lpressure
• Ra i
sehe adendo fthebe dt o30-45de gre
es.
• ma intai
nne c
kinane utralposi
tion.
• Hy perventi
la
tetot argetPCO230- 35mmHg .
• Os mo l
ardiures
is-I njMa nni
tol20%I V1- 1.
5g/k
g,t
hen0.
25g
/kgq6ht
oac
hie
ves
erum o
smo
lar
it
y
o
f315- 320.
• Seda ti
on.
• Pa r
a l
ysi
swithvenc uronium.
• Ox ygent omaintai
npO2>60mmHg .
• Ur gentneuros
urger yconsult.
• Or derCTs cano fthehe a d.
09 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Ma
nag
emento fo penfrac ture
• Remov ede bri
sa ndwo undi r
ri
gati
onwithnor
ma ls
ali
ne.
• Ster
iledr essi
nga nds pl
intthefra
ctur
e.
• Chec kt hene urov asc
ularstat
usoftheli
mb.
• Orde rXr ayoft hef r
a c
turewith1joi
ntabov
eand1j oi
ntbe
low.
• Star
tI Va nal
g e
s i
c s.
• IVa ntibioti
cs.
• Tetanuss ho t
,ifno ti
mmuni zedinthelas
t5year
s.
• NPO.
• Urgento rt
hope dicc onsul
t.

Ma
nag
eme
nto fanteri
orshoulderdislo
ca ti
on
• Post
ureo fthearm -Abduc ted& e xte
rnall
yrot
ated.
• OrderXr ays:AP,tra
ns-scapular,axi
ll
aryvi
ews.
• Urgentorthopedi
cc ons
ult.
• Clos
e dreducti
onwi t
hI Vs edat
io n& mus cl
erel
axat
ion.
• Obtainpo s
treducti
onxr ays.
• Checkpo st-r
educt
ionne urovas
c ula
rstat
us.
• Sl
ingf o
r3we eks
,fol
lowe dbys houlderre
habil
it
ati
on.

Ma
nag
ementofankl
es prain
• Foll
owOt tawaa nklerule
st oor
derXr ay
s.
• Ank l
eXr ays-AP ,
lat
eral,mo r
ti
sevie
ws.
• Resttothejoint.
• Ic
et obeusedf or5-20mi nute
se v
ery2ho ur
s.
• Co mpres
si
onwi t
hat ensorbandage.
• Elevat
ethelimb .
• Ana l
ges
ics
.
• Urgentort
ho pedicconsul
t.
• Reducewe i
ghtbe ari
ngwi thhel
po fcr
utches
.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦⇧⌥⇥⇢
✓⇥⇡ ⌦
⌦ ⌦0=

Al
lisonGe or
ge,a28yea
rso
ldpri
mi g
rav
idac
ametoy
ourc
li
nicf
orhe
rant
ena
talv
isi
t.Shewa
ntsi
nfof
or
br
eastfe
eding.
Takeafocuse
dhi s
tor
yandaddr
essherc
once
rns
.

Couns
eli
ngCa
se:
Bre
astFe
edi
ng

HOPI Pa
stHistor
y
Curr
entg esta
tiona lage? • Doy ouha v
eme dic
alil
lness
es?
Anycompl icat
ionsi nt hecurrentpre
gnancy? • Ar eyo uona nyme dica
tio
ns?
GTPAL: Gr avidity,Term pregnanci
es, • Ar eyo ual
lergi
ct oanyme dica
tio
ns?
Pr
ema t
urity, • Anys urg
eri
e sinthepast?
Abort
ion,Li vi
ngc hi
ldren. • Anyh/ ocancerinthepa s
t?
Las
tfetalultr
aso und.
Anyma ternalscreeningt i
llda t
eforgene
tic Fami l
yandSoc i
alHistory
di
sea
se? • Doy ousmo ke?Amo unt/
fre
quency.
Anygene t
icdisor derinfami ly? • Doy ouconsumea l
cohol?
Anybreastfeedingi ssuesinpr evi
ous Amo unt/f
requency.
pr
egnancies/ • Doy ouuser ecr
eati
onaldrugs?TRAPPED.
Anyrecurrentinfe ct
ionsoft hebreas
t? • Anyf a mil
yhi s
toryofcancers(es
pbrea
st
Anyh/oHI V/HCV/ HBs Ag /acti
veHSV? cance
r)?

Couns
eli
ngf orBr ea stFe e ding
• Br e
as tfeedingha stobei nit
ia t
e di mme diate
lyafterbirt
h.
• I niti
a lcl
ea rbr eastmi l
kc a l
ledCOLOSTRUM i sfullofnutri
entsa ndimmuno globul
ins.
• I tisbe nefici
a lfo rde velopingi mmuni t
yint hene wbo r
n.
• Ful lmi l
kpr o duc tions tart
sb y3- 7da y s.
• Ex cl
us iv
ebr e astf eedingi srec omme ndeddur ingthef ir
st4mo nths,
• Br e
as tmilki se as i
lydi gestedwi thmi nima lre
nalloa d.
• Br e
as tmilkha sl owa l
lergicpo t
e ntialthanc ow'smi lkprotei
n.
• Lo we rpH pr o mo tesg rowtho fla ctoba c
il
lusintheGIt r a
ct.
• Cr eatespa rent-c hildbo ndi ng .
• Br e
as tfedba bi esr equiref ol
lo wings uppleme nts
:Vi taminK, Vi t
ami nD, Ir
on(fr
om 4mo nthst
o12
mo nt hs)
,Fl uo ride (a
f t
er6mo nths ).
• Co ntr a
indica tionst obr eastfe eding -
-Mo therr ec ei
v ingc hemo thera py.
-Mo therwi thHI V/ AI DS, activeTB, he r
pesint hebr e
astregi
o n.
-Mo therc o nsumi nga lcoho l/
illic
itdr ugs.
-Mo thero ndr ug sc ontraindic atedf orbr e
astfeedinglikeantime t
a bo
lit
es,
bromo c
ript
ine,
chloramphe ni col,me tronida zo l
e ,tet
racycl
ine,li
thium, cyc
lopho sphamide.
• Co mpl icati
o nso fbr eastfeeding-s ore/cr
ac kednipples,brea
steng orgement,mast
itis
,brea
stfe
edi
ng
j
a undi ce
,br eastmi lkjaundi ce,o ralthr ushinba by.
• Br e
as tfeedinghe l
psi nl osi
ngpr e gna ncywe ight
.
• La ct
a ti
ona lame no rrheapr ote ctsa gainstfuturepregnanc y
.
• Gi vee ducatio nali nfofo rbre astfe eding.
8- ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

RachelMarshal
lisa20mo nt
hsoldgir
lbroughtt
otheERwithe
xce
ssi
vecr
ying.
Shehassi
gnsoffr
act
ureo
f
ri
ghthumerus.Youal
soobser
vesomeo l
dhe a
ledbr
uis
ese
lse
wher
eonherbody.
Sheisnowsta
ble
.Take
hi
stor
yfro
mt hemothera
nda ddr
essherco
ncerns
.

Couns
eli
ngCa
se:
Chi
lda
bus
e

HOPI • Ar et he reo therc hil

dr eni nt heho us e?
• Ho wdi dt hei njuryo c cur? • Ha v et he yha dbr okenbo ne so ro ther
• Whe ndi dt hei njur yo ccur? inj
ur i
e s?
• Lo c a
tiono finj ury? • Wa st hisc hildapl anne dpr eg na ncy,
• Wha twa sthec hil
ddo inga tthemo me ntof • Pr obl emswi thpr egna nc y,birthhi s t
ory.
inj
ury? Deta iledhi story.
• Anyl osso fco nscious ness? • De v elopme ntalmi lestone s.De tail
e dhistor
y.
• Anya bno rma lpo sitiono rpostureoft he • Wha ti sthet ypicalres pons eo fc a
regivers
body? whe nt hec hi l
dc rieso rmi sbeha v e
s ?
• Anys ei
z uresa fterthet rauma ?
• Anyv omi ting? Fa
mi l
yandSoc ialHi story
• Anye xcessivec rying ? • Doy o us mo ke?Amo unt /freque nc y.
• Anybl eedingo rdi scha rgefrom • Doy o uc onsumea lcoho l?
nose/e
ars /mo uth? Amo unt /fr
eque nc y.
• Whoa ret hec hi l
d'sc areg i
vers? • Doy o uus ere cre
a t
iona ldr ug s?TRAPPED.
• Whol i
ve sint heho us eo rcome sinc ontac
t • Al co ho li
sm/ smo k i
ng/ druga bus eb yo ther
withthec hi l
d? car
e give r
s ?
• Ho wdi dt hec hi l
dg e tthebr uises
? • Ec o no mi cco nditiono ft hef ami ly
?
• Wha tha ppe ne dwi tht heo t
herfractures? • Anypr o blemswi ththel aw?
• Anyo the rinjuriesint hepa st? • We ret hec are giv
e r
sa bus eda sc hil
dr en?
• I sthechi l
da cc identpr oneo rdiff
icultto • I sthe res pous a
la buse, sexua la buseo rincest
?
handle? • Ha st heChi ldren'sAi dSo c i
etybe en
• Wha tist hec hild'spe rso nal
ity:openv s. inv
o lvedwi tht hischildo ro the rchildren?
withdrawn.

Couns
eli
ngforc hilda bus e
• Doac ompl etephy si
calexamina ti
ono ftheba by.
• Do cume nta nd/ orpho t
o g
rapha llinjuries:t
y pe,l
o cat
ion,si
ze,shape,c
olor,
patte
rn.
• I nf
o rm pa rentso rcaretaker
sa bo utthes uspici
ono fchi
ldabuse.
• Or de rbloo dt eststoruleoutme dicalcauseso fpresenti
ngs y
mpt oms .
• Se xuallytrans mi t
tedinfect
ionwo rkup .
• Sk eletalsurve y/bonescan.
• CT/ MRI .
• Fundo scopy .
• Re po rtallsu spici
ousc as
estot heCHI LDREN' SAI D SOCI ETY.
• Admi tf orse ri
o usinj
uries
.
• I nvolveso cialwo rkerando t
he rc ommuni t
yr esources.
• I nf
o rmt ha tyo ua r
elegall
yo blig
e dtoi nformt heChi l
dren'
sAi dSo ci
ety
.
• Yo urdut yt or epo r
toverri
despa tient'sconfidential
ity
.
• Ev aluatet her iskfactor
sforc hil
da bus e:
-Env ironme ntalfac
tors-So c
ialisolat
ion,pov ert
y,domesticviol
ence.
-Ca regiverfactor
s-Pa rent
swe reabus edasc hil
dren,psychiat
ri
cill
nesse
s,subst
ancea
buse,
si
ng lepa r
entf a
mi l
y,po orsoc i
al& v ocati
o nalski
ll
s,belowa v
erageint
ell
igence
.
-Chi l
df act
ors-diff
ic
ultt e
mpe rame nt,dis
a bil
it
y,spec
ialneeds(e
gde vel
opme nt
aldel
ay)
,
prema ture.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦⇧⌥⇥⇢
✓⇥⇡ ⌦
⌦ ⌦8

Nanc
yAlfr
edo,a30yea
rsol
dwo manpres
ente
dtoy
ourc
li
nicwi
thabl
acke
yea
ndmul
ti
plebr
uis
eso
nhe
r
ar
ms.Ta
kehis
toryandaddr
esshe
rconc
erns.

Couns
eli
ngCa
se:
Dome
sti
cvi
ole
nce

HOPI • Whoa rethebi o l

ogica lparentsoft
he
• Ho wdi dt hei njuryo cc ur? chil
dr en?
• Whe ndidt hei nj
uryo ccur? • Dot hec hil
dre nwi t
ne s sphysi
c a
labuse?
• Lo c ati
ono fi njury/injuries? • As ka boutviolenc etot hechil
dren,sex
ual
• Ci rcums tance sinwhi c ht heinjuryoccurr
ed? abuse ?
• De scri
bev iolente pisode ,wha ttr
igge
redit? • I sthebo yf
riendwi l
lingt ose e
khe l
p?
• We reo bj
e ctsus eda swe a
po ns? • Anys tre
ssesa tho me /wo rk?
• Wa sthebo yfriendr emo r
s e
fulaft
erward?
• Hi storyo fpr eviouse pis odesofviol
enceor Famil
yandSoc ia
l Histor y
los
so ftempe rb ybo yfriend. • Doy ous mo ke?Amo unt /f
requency
.
• Wha twa spa tient'
sr espo nse? • Doy ouc onsumea l
co ho l
?
• Ha spatientbe enina na busiv
er el
at
ionship Amo unt/freque ncy.
before? • Doy ouus er e
c reati
ona ldrug s
?TRAPPED.
• I sboy f
riendc ontroll
ing ? • Do est hepa rt
ne ra busea lco
ho lorother
• Do esher estricthe rac tiv
iti
es? drugs ?
• Que sti
onhe re xcessiv
e lya f
tershehasbe e
n • Ec o no micsituat i
on?
out? • Anyf amilyhis t
o ryo fphy si
calabus
e ?
• Eng agesinv erbalabus eo rthreat
s?
• I sthev i
o l
enc ei ncreasingi nseveri
ty?
• Ar et herec hildrenint heho use?

Couns
eli
ngf ordome sticviolenc e
• Ex plaintha tthebo y f
riendhi tti
ngt hepa t
ie ntisac r
imi na las saulta nda ne x ampleo fdome st
ic
violence.
• Do me s
ticv i
o l
e ncet endst oi nc reaseov ert imeunl esst hev ictiml e aves, ort hea bus era ndcouplesee
k
therapy.
• Ve r yo fte
n, wo me ndo n'tlea vet he irabu s i
vepa rtnerunt i
lt he ya r
es e r
io uslyhur t.
• Do me s
ticv i
o l
e ncebe t
we ena dultpa rtne rst endst ober eflectedi nf utur ebe havioro fc hi
ldrenwho
aree xpo s
e dtoi ta ndt he r
ei sar isko fv io l
e nc etot hec hildre n.
• Chi lda busei sac rimi nala cta ndi fs uspe cted, i
sr eportablet opo liceb yl aw.
• Spo us a
la busei salsoac rimi nala c tbuti sno trepo rt
abl eb yla w.
• Re comme ndt hatt hepa tientno tr eturnt ot hea bus erift he r
ei sr i
skt ohe rs af
ety( e.g.notthefir
st
assault,abuse rno tr emo rseful).
• I fthepa ti
entdo esr eturn,ane xitpl ans ho uldbede velope dt oe nsur epa t
ie ntsafety.
• Do cume nta l
le vide nceo fabus e( picture s,sk etches)a ndr elat edv is
its; quo tepa tientdi rec
tlyinchar
t.
• Al terna ti
ve l
y,thepa tientca nc o nta ctthepo licetoo bta i
nar e st
r a
ini ngo rde ront hea buser
.
• De velopapl anwi tht hepa tientt os eeka l
te rnatel i
vinga r
ra ng eme nt s(wo me n'sab uses hel
ter)
.
• Enl i
stt hehe lpo fpa t
ient'ssuppo r tstruc ture( friends,o therf ami lyme mb er s)
.
• Co nta c
tt hepo li
ce( pa t
ients ho uldbei nfo rme dtha t
,ifc ont acted, thepo licewi lllayc hargeswhether
thepa t
ientwa ntst oo rno t).
• Co uns elpa t
iento nho wtoe nteri nt oc o ntro ll
ed, saf
ee nv ironme nt& c o nta ctwi t
ht hea buserto
discusspo ssiblethe rap yfora ng e rma na geme nta ndc o ntro l
lingbe ha vi
o rs.
• So c i
a lwo rkerr ef
e rralandpr ov i
dei nfoa bo utc ommuni tyr esour c
e s.
• Ar r angef oll
o wup .
8 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Sar
aCha ng,a55y earsoldl
adyc ametoyourc l
ini
ctogeti
nfoaboutHor
moneRepl
acementThera
py.Sheis
menopausalf
o rthepast2years.Sheishavi
ngs ig
nif
ic
anthotf
lus
he s
,mo
odfl
uct
uat
ionsa
ndv ag
inaldryne
ss.
Iti
ssi
gnifi
cantlyaff
ecti
nghe rquali
tyofl
ife
.
Takeafocusedhisto
rya ndaddressherco
ncerns.

Couns
eli
ngCa
se:
Hor
moner
epl
ace
mentt
her
apy

HOPI • Anyh/ofibroi
ds?
• Me nopausalsinc ewhe n? • Anyheadaches/
migra
ines?
• Anypo stme no pa usalble eding/spotti
ng? • Anyli
ver/
a l
lbl
adderdis
ease
?
• Anyho tf l
ushes? • Anyblo
o dclot
tingdi
sorde
rs?
• Anyv aginaldischa rge/itchiness/dr
y ness
?
• Anydy sparuenia ? Pa
stHis
tor
y
• Anyni ghtswe ats/sleepdi sturbances? • Doy o
uha v
eme dic
alil
lness
es?
• Anyc hestpa i
n/pa lpitati
o ns? • Areyouonanyme dic
atio
ns?
• Anyh/ obr eas
tl ump/ ma ss? • Areyoual
ler
gictoanyme dic
ati
ons
?
• Anyni ppledischa rge? • Anysurg
eri
esinthepast?
• Anywe i
ghtl os
s/ gain? • Anyh/ocanceri
nthepa s
t?
• Anybo nypa ins?
• Anybo we l/
urina ryc hang es? Fa
mi l
yandSocial
Hi st
ory
• Anymo odc hang e s
/irri
tabi l
ity/
de c
reased • Doy ousmo ke
?Amo unt
/fre
quency
.
l
ibi
do? • Doy ouconsumea l
cohol
?
• GTPAL-Gr avidi t
y, Term pr egnanc i
es, Amo unt/
fre
quency.
Pre
ma t
urity
,Abo rtions,Li vingc hi
ldren. • Doy ouuserecr
eati
onaldrugs?TRAPPED.
• Whe nwa slas
tPAPt estdo ne? • Anyf amilyhist
oryofcancers(e
sp
• Whe nwa sthela stbr eastexa m done ? bre
ast/
endome t
ri
alcancer
)?

Couns
eli
ngf orhor moner e pla
c eme ntt he rapy
• HRTi sre c
o mme ndedf ors igni ficantv asomo torsympt omso fmenopa
use
.
• Lo wdo seo fho rmo nesisg i
ve nf o ras ho r
tdur ati
o no f<5y ea
rs.
• Ty pe so fHRT-Or al,Trans de rma l(pa t
ch,g e
l),Co mbinede s
tro
gen& pr
oge
sti
n.
• Gi v einfo rma tionbr oc huresa bo utHRT.
• Co mpl iancet ome dic
a ti
ondo sei sv eryimpo r
tant.
• Enc oura gea nnua lphy si
cale xa mi na ti
o nwi thaf amilyphysic
ian.
• Si dee ffects:
Abno rma luterinebl eeding ,ma st
o dynia.
ede ma ,blo ati
ng ,he artbur n, naus ea,mo odc hange s.
• Co ntraindica tionst oHRT:
Pr e-existingunc ont r
olledhy per te
ns i
on.
Ut erinef ibro i
ds ,endo me trio sis.
, migraine.
Fa mi lyh/ oe stroge nde pe nde ntc ancers.
Chr onict hro mbophl ebiti
s ,di abe t
esme l
lit
us.
Impa iredl iv
e rfunc ti
on/g a llbla dderdisease.
Hy pertriglycer i
demi a,fibro c ysticdi s
easeo fthebr eas
ts.
• HRTi spr otec t
ivea gainsto ste opo ro t
icfracturesandc o
loncancer
s.
• HRTi ncrease sr i
skf or:
Inv asivebr eastc anc e
r.
Co r onaryhe artdis eas
e .
De e pv eint hro mbo s
iso rpul mo narye mb oli
sm.
St r
o ke.
De me ntiaa ndmi ldc og nitiv eimpa ir
me nt.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦⇧⌥⇥⇢
✓⇥⇡ ⌦
⌦ ⌦8%

NadiaSol
ans
ki,
a45yea
rso
ldla
dyc a
met oy
ourcl
ini
ctog
eti
nfoa
boutma
mmo
gra
m.
Ta
k eafo
cuse
dhist
orya
ndaddr
essherc
once
rns
.

Couns
eli
ngCa
se:
Mammog
ram

HOPI Pa
stHistor
y
• Anyh/ obr ea s
tl ump/ mass? • Doy ouha v
eme dic
alil
lness
es?
• Anybr eastdi scharg e? • Ar eyo uona nyme dica
tio
ns?
• Anyni ppledi scha r
g e? • Ar eyo ual
lergi
ct oanyme dica
tio
ns?
• Anyt raumat ot hebr east? • Anys urg
eri
e sinthepast?
• Anya bno rma lsk i
ndi sc
o l
orationo fbrea
st? • Anyh/ ocancerinthepa s
t?
• Anybr easts urgeries/biopsies?
• Anyf ever/mi ghts we ats/
we i
g htloss? Fa
mi l
yandSoc i
alHistory
• Anybo nypa ins? • Doy ousmo ke?Amo unt/
fre
quency.
• Anybo we l/urina r
yc ha nges? • Doy ouconsumea l
cohol?
• Whe nwa sy ourf i
rstme nstr
ua lperiod? Amo unt/f
requency.
• Whe nwa sthel a s
tme nstrualperiod? • Doy ouuser ecr
eati
onaldrugs?TRAPPED.
• Anyi rr
e g
ula ri
tyi nt heme nses? • Anyf a mil
yhi s
toryofcancers(es
pbrea
st
• Anydy sme no rrhea /me no rr
ha gi
a / cance
r)?
ol
ig
ome no r
r hea?
• Anypa ssageo fclots?
• GTPAL-Gr avidity,Te r
m pr egnancies,
Pr
ema t
urity,Abo r
tio ns,Livingc hi
ldren.
• Ag eatwhi ch1 stchildde liv
e r
ed?
• H/ obreastfe eding?
• Whe nwa sla s
tPAPt e
stdo ne?
• Whe nwa sthel a s
tbr easte x
a m done?

Couns
eli
ngf
orMa
mmog
ram

• Ma mmo g ramisa na nnua lscreeningt e

stfo rt heearlyde tecti
ono fbreastcanc er
.
• Breas
tc anceristhes ec ondl eadingc auseo fc ancermo r t
alityinwo me n.
• Every1i n9wo me ni nCa na daa rediagnos edwi thbr eastcanc e
r.
• Iti
srecomme nde da ft
e rthea geo f40y ea
r so rmo ref orev e
r ywome n.
• Iti
sdo nea nnuallyo re very2y earsasar outinepr eventivete st
.
• Ift
hereisas t
rongf ami lyhi sto
r yo fbre
a s
tc anc erorg eneticpre-disposi
tiont obreas
tcance
r,t
hen
mammo grami sdo ne5- 10y earspr iortothea geo fthere la
tivedetectedwit hcancer
.
• Therea r
et wot ypeso fma mmo g r
a m -Scre eninga ndDi agno s
tic.
• Diagnosticma mmo g r
a mi sdo nei nc as
eso fbr e
astma ss/lumps /s
uspiciono fbreas
tcancer
.
• Ma mmo g ramisas pecialXr ayo fthebr e
a stdo nei nadi agno st
icradiol
o gyc l
ini
c.
• Thepr oceduremi ghtc auses li
ghtdi scomfo rto rpainwhi c hlast
so nlyfews econds.
• Itc
ant akeupt o20mi nut estodoama mmo gram.
• Imagesarei nte
rpr e
t edb ya ne xper i
encedr adio l
ogists.
• Incaseofa nya bnor ma l
ity,furthert es
tswi l
lbea rr
a nged.
• Ide
allyma mmo grams ho uldbedo nea ft
ery o urper i
odha sstopped,toa v
o i
ddi scomfor
t.
• Giveinforma ti
onbr ochur esforma mmo gram.
• Encourag eannua lphy sicalex a
mi na t
ionwi thaf amilyphy sicia
n.
8> ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

Je
nnaMa r
ti
nisa28y
earsnewmothe
rwhoha
sco
nce
rnsa
boutt
hei
mmuni
zat
ionf
orhe
r2mo
nthso
lds
on.
Takehi
st
oryanda
ddr
essherco
nce
rns.

Couns
eli
ngCa
se:
Immuni
zat
ion

HOPI
• Tak
ede tail
edpr enatal
/antenatalhis
tory?
• Anycompl ic
ationsdur i
ngpr egnanc y
?
• Anycompl ic
ationsdur i
ngde liver
yt i
me ?
• Anypostpa rt
um c ompl i
cations?
• Anyh/og eneti
cdi sordersinthef amil
y?
• Anyh/oe gga l
lergies
?
• Anyall
ergiestome dica
tions?
• Fe
edingpa tt
ern?
• Devel
opme ntalhi s
tory?
• Anyfever/vomiti
ng /i
rri
tabili
ty?
• Anybowe lcompl aints?
• Anyurinarycompl a i
nts?
• Anyneo nata
ljaundi ce?
• Heari
ng& v isi
o nte s
tsforthene wbo r
n?
• Anyiss
ue sduringne wbo rnex a
mi nat
ion?
• Anyh/oc omplica t
ionsafterimmuni zati
oni
nthef
ami
ly
?

Couns
eli
ngf ori mmuni zation
• As ka boutt hepa tient 'sc onc e
rns?
• Wha tdo ess hewa ntt ok no wa ndwhy ?
• I mmuni za t
ion( vaccina ti
o n)isawa yo fc re
a t
ingi mmuni tytoc ert
aindi seasesbyus i
ngs ma llamo unt
s
ofak i
lledo rwe ak ene dmi cro
orga nismt hatc ause sthepa rt
iculardisease.
• Ex pla intha tv a
c ci
ne spr otectchildrenf rom di pht heri
a,teta
nus ,pertussis,poli
o( DPTP) ,mumps ,
mea sles,rubella(MMR) , i
nf l
uenza( Hi b)a ndhe pa t
it
isB( He pB) .
• Al lo fwhi chwe reo nc ec ommo na ndc a useds eri
o us,some t
ime sfatalil
lne ssinCa nada,andno w
thesedi seasesareha rdl ye verseenbe c
a useo fv accines.
• Ex pla intha tthev ac cine ss ti
mul at
et hei mmunes y st
em.
• I nf
a ntsa refullyc apa bleo fg e
ne r
at i
ngpr ot
e ct
ivehumo r
al& c ell
ularimmuner esponsestomul tiple
vacciness imul t
ane ous ly.
• Thet i
mi ngo fvaccine si si mpo rt
ant ;s
o mev accine saremo steffec
tivewhe ng iventochildrena ta
parti
c ularag eo rinc o mbi nationwi tho therv accine s
.
• Ev er yba tcho fv accinei stestedfo rsafetya ndqua lit
yinCa na dabe forei tisrel
easedforpubl i
cus e.
• So mec hildre nha veat e mpo r
arys orear m( withi ndur at
iona ndt enderne ss)attheinject
io nsi
te,
mala i
s e
, mildf evero rr a sh.
• Al lergicre acti
onst ov ac cinesalsoo ccuri ncludingur t
icari
a,rhinit
is,ana phy l
axi
s.
• I ti
sv eryraret oha veamo reseri
o usrea cti
on( seizures,encephalopathyha vebeenr eport
e d).
• St anda rdmo de rnv acc inesa reno tk nownt oc ausedi sea
seo rtoha velo ng -te
rm delete
riouse f
fects.
• Ther is
kso fv accinatio nsa resma l
lc ompa r
edwi tht hehe a
lthrisksas s
oc iatedwiththedis ease
s
they'reintende dt opr ev ent.
• Ex pla inther e c
o mme nde di mmuni zati
o ns chedul e(below):
Gi vethepa tients omei nforma tionpa mphl ets,
invitefurt
he rque s
tionsanda skhe rtoreturn
i
nt wowe eksf ort hechild'sfirstimmuni zati
on.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦⇧⌥⇥⇢
✓⇥⇡ ⌦
⌦ ⌦80

Ja
me sHendri
kisa40y ea
rsoldma nwhocamet
oyouro
ffi
cet
oda
ytodi
scus
shi
swe
ighti
ss
ues
.Hi
scur
rent
weig
htis250lbs
,He i
ght5f e
et7inches
,BMI39.
2.
Takehi
stor
yanda ddr
esshisconc
erns.

Couns
eli
ngCa
se:
Obe
sit
y

HOPI • Cr isi
sinpa ti
ent'slif
e ,st
res
s ,anxi
ety
?
• Dur ationo fwe ig htg ai
n? • As sesspati
ent'ss e
lf-image: doespat
ientf
eel
• Amo unto fwe i
g htg ai
n? underweight,ove rweightorno r
mal?
• Di e taryha bits:f
r equencyo fme a
ls,snacking, • Do espat
ientfe elthatwe i
g htinter
fer
eswit
h
eat
inga tnight ,foo dseate
n, bingee ating, heal
th,acti
viti
e s
?
guiltabo utfo od, ho a
rding,conc ea
linge ati
ng • Sc reenforeatingdi sorders
.
fr
omo thers.
• Es tima tedda ilyc alori
cinta ke
. Pa
stHistor
y
• Ex e rci
s ehistory. • Doy ouha veme dicalil
lnesses?
• Di se asesassoc i
ate dwi t
hwe i
ghtg ain: • Ar ey ouona nyme dic a
tio
ns ?
hypo thy r
oidism, DM t ypeI I,Cushi ng's, • Ar ey oualle
rgict oanyme dicati
ons?
majo rde pression, anxie
tydi sorder
, some • Anys urg
e ri
esint hepa st?
me dications( TCA, st
eroi
ds ,OCP) .
• Pr oble msa ssociatedwi thov erwe i
g ht:gout, Fami l
yandSoc i
alHi st
or y
sl
eepa pnea ,
c holec ys
tit
is,
ba ckpa in, • Doy ousmo ke?Amo unt/
frequency.
car
di ov as
culardi sea s
e,hemo rrhoids ,l
owe r • Doy ouco nsumea lc
o hol?
l
imbj ointpa ina ndo s
teoarthri
t i
s. Amo unt/fre
que ncy.
• Whyi spatients eek i
ngme dic
a lhelpfo rthi
s • Doy ouus erecreationaldrug s?TRAPPED.
now? • Anyf amilyhistoryo fcancer s
?
• Pa sta ttempt stol osewe ight,successes, • Anyov erweightr ela
tives?
obstacles,goa l
s.

Couns
eli
ngf
orObe
sit
y

• Mo ti
v a
tio n: howwo uldbe inga tidea lbodywe ightimpr ovethepa tient'slif
e?
• Empha sizehe alth,li
fest
yle ,selfe st
ee m, r
elat
ionshipbe ne f
its.
• Dis cussnut rit
ion-relat
edpr oble ms: heartdiseas
e,o be
sity ,
hy pertens i
o n, ost
eo po r
o si
s,ane mia,denta
l
deca y,canc er,gastr
o i
ntestina ldiso r
de rs
, r
espira
toryc o
mpr o mise,hig hl i
pids, diabe t
es,sleepa pnea,
osteoa r
thr it
is .
• Dis cussdi etstrieda ndwhyt he sefailed.
• Faddi etsinv olveunus ualo re xtremee ati
ngpa tt
e r
nsa nda reno tde si
g ne dtobema i
ntainedf ora
li
fetimet here f
oret hesesho ul dbedi scouraged.
• We i
g htlo ssa gentPo ndera lnol ongera vai
lable.
• SSRI ssuc ha sPa xilma ya ssistwi thwe i
ghtloss,unfortuna tel
y,whe nt hedr ugi sdi scontinued,mo st
peo plere gainwe ig
ht .
• Ex plaint hatt hebr ainha sas at
ietys etpo i
ntwhi chc anber esetov ert imewi thr eductioni nc a
lori
c
int
a ke .
• Wa rntha tt hebo dy '
sabilityt ode termi necalori
cc ontenti sveryg o
o d, andwi llno tbefo oledb yso-
cal
le ddi etpr oduc t
s .
• Re comme ndaba l
anceddi e tco nsist
ingo fo r
dinaryf o
o ds ,witht hreedi stinctme alsperda yo fsmall
siz
e .
• Noe atinga tnighta ndbec aref
ulo fs nacks.
• Info r
m pa ti
e ntthathewi llbehung ryf oratleas
tt hefirsttwowe ekso fr educe dint a
ke .
• Sug ge s
tv isua l
izati
o ntechni que s,redirect
iono finter
ests, andtot hi
nko fhung e rasas igno fpo si
ti
ve
prog res
so nwe i
g htloss.
• Gr oups uppo r
tc anbebe ne ficialtoo :We ightwa tc
he r
s, overeatersa no nymo use tc
.
88 ⌦
⌦ |
↵ ⌦✏ ⇣⌦⌦⌦⇧⌫ ⌅
✓ ✓⇥⇢ ✓⌦
⇠✓ ✓!

• Behaviormo difi
cati
ona ndpo si
ti
veo utl
oo ki svit
alf orwe ig
htlossregi
me .
• Diet
a r
yr ecomme ndati
o ns:re
ducefatto20%o fcal
o ri
cint a
ke.1200-1600k c
al/
dayforma
les
.
• Ide
alcalo r
icint a
kec anbee sti
ma t
eda t10- 12Ca l
/lbs(idealweight)i
nma l
es.
• Empha sizetha tcalor
icintakeismo reimpo rt
antfo rwe i
g htlos
sthanfo o
dc omposi
ti
on(i
.e
.exc
ess
ive
cal
orie
sle adt owe ig
htg aineveniftheya reno n-fat).
• Exerci
ser ecomme ndat
io ns:
30mi nuteso fmo derat
ei ntensit
yexerci
se,4-5days
/week.
• Suddeni ntensee xer
cis
ei nsedentar
ypa ti
e ntunwi se.
• Mo r
ev i
g orouse xerci
sec anbeinit
iatedwhe nwe ightislo st
.
• Behavioralmo di
fi
c a
tions,se
lfcontr
ol,rewa rdso nac hie
vingg oal
s.
• Arranger egularfoll
ow- upforbodyma s
smo nito
ringa ndc ounsel
ing.
⇥ ◆
⌦◆⇢
✓⇢⌦
/⌦⇧⌥⇥⇢
✓⇥⇡ ⌦
⌦ ⌦8'

Pet
erHarperisa35yearso
ldma n,
whoi sac
hro
nics
mok
erf
ort
hepa
st10y
ear
s.Hec
amet
oyo
uro
ffi
ce
to
daybecausehewant
stoquitsmoking
.
Takehi
st
or yandaddr
esshi
sconcer
ns.

Couns
eli
ngCa
se:
Smoki
ng

HOPI • Ho wma nyt ime shaveyout ri

edtoquit
• Dur ati
o no fs mo ki
ng ? smo king?
• Fr equenc yo fs mo kinginada y? • I fy outri
edt oquitbefore
, whatme t
hodsyou
• Atwha ta gedi dy ous tartsmoking? us e
d?
• Wha ttypeo ftobacc odoy ousmo ke
- • Wha tchallengesy ouface
dwhi lequitt
ing
?
cigar
e t
te/c i
g ars/pipe /f
ilte
r/nonfil
ter
? • Wha tme tho dshe l
pedyoui ntheplan?
• Whe ndoy o uha vey ourf i
rstc
igaret
teoft
he • Wha tisyo urmo t
iva
tio
nt oquito nthesc
ale
day? o f1-10?
• I fyoudono ts mo kef orawhi l
e,doy ou
experiencec rav i
ngso rwi thdra
wa l Pa
stHistory
sympt oms ? • Doy ouha veme dic
alil
lnesses
?
• Whi chs y
mpt omsdoy oue xpe
rience • Ar eyo uona nyme dic
ations?
-we ak& t ired? • Ar eyo uall
e rgi
ct oanyme dicat
ions?
-sado rblue ? • Anys urge
ri esinthepast?
-irri
tableo rc ranky ? • Anyh/ oca ncerinthepa st?
-diffi
c ul
tyc oncentrating?
-restless
ne ss? Fa
mi l
yandSoc i
alHi story
-anx i
o uso rjitter
y ? • Doy ouc onsumea l
cohol?
• Wha tpe ople,placeso reventsma keyoucr
ave Amo unt/f
re quency.
acigarette? • Doy ouus er ecr
eati
onaldrug s
?TRAPPED.
• Ho wdo essmo kinghe l
py ou? • Anyf amil
yhi s
toryofcanc er
s?
• Do essmo kinghe lpo rha rmy our • Oc cupa t
ion?
rel
ati
o nships ?
↵⌥⇤
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Al
pha
bet
ica
lInde
x
Abo rtion-c l
ini ca lc ase.
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.118 Co llateralLi game ntSt ability
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Ac eta mi no phe n. .
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.8
Ac ut eBr onc hi olitis...
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.45 Co ng estiveHe a rtFa ilure-c l
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.104
Ac ut eCho lecy stitis...
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.24
acutec onf usio na ls tate..
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.52 Cro hn ’
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.17
Ac ut eGa stro ent eritis..
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Ac ut eMy oca rdia lI nfarction..
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.7 De epVe inThr o mbo sis-c li
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.146
Ac ut eOt iti
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.45 De l
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.52
Ac ut ePa ncre atitis..
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.17 De l
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.135
Ac ut ePha ry ng itis..
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.23 De l
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.36
Ac ut ePy elone phr it
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.23 De me nt ia-c linic alca se...
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.136
Alc oho l....
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.35 De pre s
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.56
Alc oho lwi thdr awa l...
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ini calc as e.
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.137
AllenTe st..
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.68 Dia betesMe l
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.14
Aller gicr eac tion. .
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.50 Dia beticFo ot-c li
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.147
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.31
Ana phy laxis.....
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.14
Ane mi a....
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.32
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.84 Dig ox i
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.106
Ano rexia-c lini calc ase.
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.133 Div erti
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.17
Ant e nat alVi sit-c l
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.119 Do me sti
cv iolenc e-c o uns eli
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.161
Ant e riorDr a we rTe s t
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.82 Dy sfunc tionalUt er i
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.40
anti- hype rtens ivedr ugs.
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.10 Dy sli
pi demi a...
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.9
Apl ey '
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.86 Dy sme no r r
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.16 Ecto picPr egna nc y..
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.42
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.86 Ecto picPr egna nc y-c li
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.120
Arr hy thmi a s...
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.31 Eme rgenc yc ont racept io n...
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.41
ASA. .
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.31 Empt yCa nTe st. .
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.86
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.24,45 Endo me triosis.
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.40
As thma-c linic alc as e
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.103 Epig lottit
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.48
Athl e t
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.13 Ethy leneg l
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.32
Atr i
a lFi br i
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.8,102 Exa mi na t
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.63
Atr i
a lFi br i
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o n-c l
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.102 Exa mi na t
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.77
Atrophi cv a gini ti
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.39 Exa mi na t
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.90
Bac kPa in-c linica lc ase
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.142 Exa mi na t
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.65
Bac te r
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.71
Bac te r
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.46 Exa mi na t
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.87
Bac te r
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.45 Exa mi na t
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.83
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.88
Bas alCe l
lCa rc i
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.143 Exa mi na t
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.79
Beni g nPr osta ticHy perplasia-c li
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.144 Exa mi na t
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.81
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.57 Exa mi na t
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.75
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.78 Exa mi na t
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.159 Exa mi na t
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.67
Bue rg er'sTe s t..
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.69
Bul i
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.134 Exa mi na t
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.85
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.11 Exa mi na t
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.91
CaOe sopha gus-c linicalca se
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.148 Exa mi na t
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.73
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.39 Exte rnalRo tationLa gSi gn..
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.86
Ca rpa lTunne lSy ndr ome-c linicalcas
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.145 FABER. .
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.78,80
Ce llulitis.
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.13 Failuret ot hrive-c linic alc as
e .
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.126
Ce rebr ov ascul arAt ta ck-c linicalcase.
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.105 Febr i
leSe izures....
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.49
Che stPa i
n-c linic alc as
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.111 Febr i
les eizures-c l
inic alc ase.
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.127
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.160 Femo ralst r
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.78
Chl a my di a.
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.38 Fi
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.29
Clus terhe ada c he .
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.22 Fi
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.89
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.54
Al
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PainAbdo me n-c linica lcase...
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.151
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.53
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.38 PanicAt tack-c linic alc ase..
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.139
Gerbe rLi ft -Of fTe st
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.86 Panicdi sor de r.
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.53
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.34 Parkins o n’
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.23
Golfer '
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.87 PatellarAppr ehe ns ion.....
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.82
Gono rrhe a ..
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.38 PatellarGr ind......
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.82
Gout ...
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.27 Pedicul os i
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.13
GroupASt re pto c occus .
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.48 PelvicI nf l
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.40
GroupBSt rept o co ccus..
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.41 Pelvici nflamma tor ydi se as
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.123
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.59 Pembe rto n'ss ign. ...
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.91
Hawk insI mpi ng e me ntSi gn..
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.86 Pepticul cerdi sease ...
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.19
Hea da che-c lini calca se.
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.110 Periphe ra lVa scula rDi sease-c l
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.152
Hea rtFa ilur e.....
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.8 Pertus si
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.48
Helico ba cte rPy lori..
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.17 Pha l
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.89
Hema te me sis-c linicalca s
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.149 Phe nc yclidi ne....
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.59
Hemo t ho ra x-c linicalc ase.
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.156 Placent aPr e via-c linica lca s
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.124
Hepa titisB. .......
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.18 Planta rFa sciiti
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.84
HIV. .....
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.19 Pneumo nia-c linic alc ase..
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.112
Hor mo neRe pl ace me ntThe ra
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.41 Polymy alg iaRhe uma tic a.
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.28
HRT-c ouns e ling ..
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.162 Poste xpo sur e-c linica lc as
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.113
Hor ne r'ss ydr o me ...
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.69 PostOpe ra tivef ev er-c linicalca se.
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.153
Hype re me sisGr a vidarum. ...
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.42 Post-tra uma t i
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.55
Hype rpr o lac tine mi a.
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15p. Poster i
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.82
Hype rt ens io n........
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.125
Hype rt hy ro idis m. ...
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.15 Pregna nc yI nduc edHy pertens i
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.41
Hypo g ly cemi a .
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.32 Pri
ma ryno ctur na le nur esis-c l
inicalcase.
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.130
Hypo t hy ro idis m. ....
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.15 Psoriasis .
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.12
Immuni za tio n-c ouns eli
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.164 Psycho s i
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.56
Immuni za tio nSc hedul e.
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.50 Pulmo na ryEmbo lism. ....
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.25
Impo te nc e......
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.16 Pulmo na ryEmbo lism -c linicalc as
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.114
Impo te nc e-c linic alca se
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.108 Pulmo na ryt ube rcul osis...
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.20
Inf
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.107 Pyelo ne phr itis.
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.39
Inf
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.10 Pylorics teno sis-c linic alca s
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.131
Inf
er t
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.121 Rabi es...
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.20
Lachma nTe st.....
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.82 Rhe uma ticHe ar tDi sea se.
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.10
Laryng otra c he obr o nchi t
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.48 Rhe uma to idAr thr itis...
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.26
Laseg ue 'ss ig n......
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.78 Rombe rg’st est...
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.72
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.20 Scabie s...
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.13
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.163 Schiz ophr e ni a-c linica lcase....
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.140
Ma nia .
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.53 Scho be r'sTe st.
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.78
Ma nia-c lini ca lc ase...
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.138 Seizur edi so rde r-c linic alcase .
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.115
McMur ray '
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.82 Seizur es...
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.21
Mea sles-c lini ca lc as
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.128 SepticAr thr it
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.29
Meni ng iti
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.21 se
xua ldy sfunc t
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.58
Meni ng iti
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.109 Sexua llyTr ans mi tte dI nf ecti
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.38
Mig raine .......
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.22 Sho ck .
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.33
Mo o ds ta biliz ers .
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.57 Smo king ..
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.35
My asthe niaGr avis .
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.23 Smo king-c o uns eling ....
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.167
NeckSwe lling-c linicalcase..
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.150 SocialPho bi a..
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.54
NeerI mpi ng e me ntSi gn..
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.86 Solitaryl ungno dul e-c linicalca se.
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.154
Neo na talJ a undi ce-c linicalcase
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.129 Spee chde la y-c linic alc ase..
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.132
Obe sity-c o uns e ling...
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.165 Spee d'sMa ne uv er .
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.33
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.122 Str
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.33 Str
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.33
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.26 Suicide-c linica lc ase .
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.84
Al
pha
bet
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lInde
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Syphili
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38 Tre
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84 Tri
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34 Tro
isie
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50
Tempo ralAr ter
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116 Ulc
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87 Uri
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29
Tensionhe adache.
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22 Uri
na r
yTr a
ctI nfect
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39,49
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21 Vir
alHe pa ti
tis-c l
inica
lcase.
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117
Tho mast es
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80 Vir
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84 Vocalf
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70
Thy ro
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155 Vul
vovag i
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39
TineaCr uris..
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13 Warfari
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34
Tinel'
ssign...
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89 Who opingCo ugh...
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48
Tr
e ndele
nbe rgtest.
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79 Yer
gasont est..
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86