Taiwanwalker CS note

Section 1 General History/PE

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

Section 2 Case Discussion

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

Eyes and ENT Respiratory Cardiovascular

Chest pain/ Palpitation

pg22 pg23 pg25 pg26

Blurred vision/ Sore throat/ Loss of hearing/ Hoarseness

SOB&Cough/ Hemoptysis/ Asthma drug refill

Neurology

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

Urology

pg30

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

Rheumatology/Musculoskeletal

pg32

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

Obstetrics/Gynecology

pg36

Dyspareunia/ vaginal bleeding /vaginal discharge/ Hot flashes positive pregnancy test/ Amenorrhea

Pediatric Phychiatry Abuse/Assult Constitutial Symptoms Others

pg38 pg43 pg45 pg46 pg48

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

Anxiety+SOB/ Depression /Insomnia/ Phychosis

night sweats/ Fatigue/ Weight gain/ Weight loss

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

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

Section 1 General History/PE

Regular history #Begin Knock on the door(wait 2 seconds) Hello Mr/Ms.XYZ nice to meet you,(shake hands) I am doctor Lin the duty doctor today, and I am here to ask you a few questions. Let me make you more comfortable(drape the patient) So, What cause you to come in today?-->I am sorry to hear that Can you tell me more about your problem? #HPI: LQQ OPERA, ask PDF alone with O, or LIQURAAA Location:Where's the location of the pain? Quality:Can you describe your pain? -->for example, sharp/dull/burning/or pressure like? Quantity:On a scale of 1-10, with 10 being the worst, how would you rate your pain? Onset:When did it start? How did it start?what were you doing when it started)?(Past: Did you experience the same problem before? Duration:How long does it last?Frequency(timing):How often does it occur? Is the pain constant or intermittent ? Is it getting better or worse? what time in a day does it usually present? Precipitation: Do you remember anything that might have caused it? Is there any relationship with food and the pain(in epigastric pain case)? any relationship between the position and the dizziness? Excerbation:Do you know anything can make the pain worse? Relieving(Radiation): Do you know anything can make the pain better?The pain move to somewhere else? Have you tried anything to help? Associated symptoms:Do you have other symptoms right now? -->Is that all the symptoms you have? #PHM: PAM HUGS FOS EAST SODA . Begin with transition sentence: I need to ask you few questions about your health in past, is that okay? I need to ask you few questions about your family health, is that okay? Can I ask you about your about your sexual and personal life, It'll be confidental--> if no answer: I would like to know the whole pictures of your health condition and your infomation can be very helpful,(pause) is that Ok? Past medical history: Do you have any illness in the past?any operation?any trauma?(Dizziness, pain cases, headache) ,Easy bleeding(In any bleeding case),DM/HTN/Hyperlipedemia(In limbs weakness/ numbness,erectile dysfunction) Allergy:Are you allergic to anything? Medical:Medication:Are you currently taking any medication including over-the counter medication and prescribed medication?Side effect? Procedure: Any blood transfusion?(in anemia cases), when is your last PPD?(if suspected TB) , Have your colon been examined with any device?(colonscope in jaundice/blood in stool case ) Hospitalization: Have you been admitted to hospital before? Urinary:Do you have any urinary symptoms ? Do you have trouble urinating ? Is there any change to your urine habit? Is there any change to urine color? GI:Do you have any bowel symptoms for example loose bowel?Is there any change to your bowel habit?

Is there any change to stool color? Sleep:How's your sleep recently? If not good->see insomnia

Family:Is there any illness in your family? Ob/Gyn:When was your last menstrual period?(ask in detail if needed) OB:(GPA+complications)How many times you have been pregnant?how many children did you give birth to? Have you ever had miscarriage?abortion? In which trimester?Any complication during pregnancy? GYN:Symptoms:Do you have vaginal discharge/bleeding?Pain during intercourse? Any problem controlling bladder Past problem :Did you performed Dilation&Curettage, Did you have uterine infection (in Amenorrhea case), Did you use Intrauterine device? (in abdominal pain/vaginal discharge case) MP:MP Description:When is your first menstrual period? How often is your menstrual period? How long does it last? How many pads do you use in a heavy day? MP complications: Is there any changes to your menstrual period? Have you ever bled between cycles? Do you have abdominal pain with your period? (in dyspareunia) Pap smear:Have you had a pap smear? What's the last time you did a Pap smear?What's the results of the Pap smear? Sexual:Are you sexually active?(In details: How many sexual partners do you have in last 6 months? Men, women or both? -->Men specific:(Condom/impotence) Do you use condoms? Is there any change in your sexual function lately (if suspect impotence) -->Woman specific(Condom/Contraception): Does your sexual partner use condom? do u use any birth control pills? -->If high risk sexual behavior:(STD/HIV)Have you had sexually transmitted disease? Have you been tested for HIV? (Also ask STD in lower abdominal pain/UTI/joint pain case) Exercise:Do you get any exercise? Appetite(Also Diet and Weight):Is there any change in your appetite?What's your diet? Is there any change in your body weight? Stress/support system(Also mood): Do you have any stress? Do you have anyone who can support you? (in physiological problem) How's your mood? Travel: Travel:Have you travelled recently? Did you have any immunization before travel?Any picnic/ camping(If GI case)? Expose:Have you been exposure to animal? Have you been bite by insects?Have you been in contact with sick people?(If GI/URI/TB)? Smoking:Have you been smoking? How much? Occupation:What's your job? Is your job stressful? Drug:Have you been using any recreational drugs? (Heroin cause constipation, cocaine cause MI) How do you take it? How often do you take it? When was the last time you took it? Alcohol:Have you been drinking alcohol? if yes->how much do you drink, how long have u been drinking ->If drink a lot-> ask CAGE Cut:Do you feel that you need to cut down on your drinking? Annoyed:Does anyone complain about your drinking? Guilt:Do you feel guilty about your drinking? Eye-opener:Do you drink alcohol in order to get rid of a hangover?

#Conclusion: Summarize history:Right now I would like to summarize your history(Ex: you have chest pain for 5 days , it's progressing and it's burning. Also you have nausea and vomiting, is that right?) Summarize PE: Explain Diagnosis and Lab to do:(Ex:According to your history and physical examination, you might have a a inflammatory process of the esophagus, but we are not sure yet, so we would run some blood tests and we will do an image test to see the anatomy of your esophagus (also explain pelvic exam/rectal exam in low back pain/abdominal pain case) Counselling:Also as a concerned physician, I would like to talk about your smoking/alcohol/unsafe sex/DM /HTN/current problem Ask questions: Do you have any questions or concerns? Challenge questions:Do I have XYZ/ Do I need OP?There's possibility, but before I can answer your question, I would like to run some tests, I will study the results carefully, and we will sit down and discuss it all over again, I will make sure you are conformable during the examination. If still have time:Can you think of anything that you want to tell me and I forget to ask? Ending: Thank you verry much, Mr.Green, I will try my best to help you to get better, Please take care for now. Challanging Questions Patient tells a lot of stories Mr. Smith, sorry that I interupt you, but right now I want to focus more on your physical condition, I will try to find another time and you can tell me more about your trip, is that OK? Patient says not interested to talk Ms Green I understand it's really a tough time for you, but your condition could be cause by some medical problem, I will try my best to help you to feel better, can you try to answer my question? Just give me some pain killer Ms Green, I understand that you are in pain, but I need to ask a few questions to understand your pain, then we can give your safe treatment for your pain. I want refill before the lab test I will try to contact with the doctor who prescribed you medication to give you 1 or 2 days extension You are a good doctor so thats why I come for refill I am flattered, but I have to evaluate you again to study the safety of the medication, its my commitment to be careful. Why are you asking so many questions? I would like to know your general health as a whole to find out whats wrong to give you the right treatment, so can you tell me more about ... Do I have AIDS? I am also concerned about the possibility, I would like to run so HIV test to you, is that OK?

Will my insurance company going to pay for the test? I am not sure, but I will refer you to a social worker to find that out, also I can write a letter to your insurance company to show how important is the test. Can I go back to work? Its seems like work can worsen your condition, also I can write a letter to your employer to explain your condition. Am I going to die? Your condition raise my concern, most of the people will have symptoms improve after the treatment, however, no matter whats happening, I will be at your side and I will try my best to help you I need to go home for my child I understand your concern, but according to your situation its your best interests to stay in the hospital,we have wonderful social worker who can solve your problem Why do we have to live? Life could be challenging, but I will try my best to make you feel better, is there any specific things on your mind which is bothering you? Will I get better? Its hard to tell at this point, but most of the people would feel better after the treatment. I am in abdominal pain, can I have some water? I am sorry I cant give you any water right now in case you need an emergency operation. I am afraid of OP Its very common to have the feeling for operation, however, I will make sure you are comfortable during the process. Have HIV/STD, do I have to tell my wife? (Do you think he is cheating on me) I know its difficult, but you should discuss with her in person, its important to have you both evaluated and treated at the same time if the result is positive. Its just because I am getting old. Age could play a role in your problem, but we still have to rule out other causes like..., so I have to run some test on you and I will study it carefully. What is ultrasound/EKG(Explain first, don't wait till they ask) Ultrasound:A machine using sound wave to detect your internal organ EKG:A machine detect electrical activity of heart CT/MRI :special imaging test to detect your organ Endoscope:A tube connected to a camera to see into your bowel/respiratory tract TSH: blood test for your thyroid activity Pap smear: A test to collect your cervical cells to see if theres abnormality Is this tumor malignant? I cant answer your question until I get pathology report, I will read the results carefully and well discuss it all over again, no matter whats happening I will try my best to help you

Where have you been, I am waiting for a long time I am very sorry you had to wait so long, but now I am here and will totally focus on your concern My mother has cancer, does it mean I will have it too? The risk is increased, but doesnt mean you will get it, so regular screening test is very important. Losing pregnancy in vaginal bleeding? The risk is increased, but doesnt mean you will lose it, so regular checkup is very important. Tubal ligation get pregnancy? The risk is small, but theres still possibility I heard herbal therapy works. I heard that herbal therapy could be helpful to many disease, let me know the name of herbal therapy and I will study carefully about its safety and efficacy HRT cause breast cancer? Its appears to be true, so thats why HRT is only used with limited time to relief hot flashes Crying:Tissue + touch shoulder: It must be very difficult for you, would you please tell me more about it Compliment on cloth/hairstyle, ask about your personal life Thanks for the interests, but right now I would like to focus on you in order to help you. Change subject when ask about sex/drugs: Ive notice that you changed subjects while asking, Ill try my best to help you, please tell me whats your concern? Difficult Questions Urinary: irritative symptoms:screening with "Is there any change to urinary habits? Urgency:Do you feel like you have to go to toilet right away once you feel the urge? Frequency:Do you feel like you have to urinate all the time? Nocturia:Do you need to get up in tthe night to urinate? Obstructive symptoms: screening with "do you have any trouble urinating?(HIS Dimished PI) Hesitancy:Do you Need to wait for the stream to begin? Intermittency Is the stream starts and stops intermittently? Straining: Do you need to push hard during urination and only little urine comes out? Diminished stream:Have you noticed any weakness in your stream? Postvoid dribbing:Any dribbling of urine after urination? Incomplete bladder emptying: sensation of not emptying your bladder completely after finishing the urination?? Bowel: Decrease stool caliber Do you feel the size of the stool is decreasing? Tenesmus:Do you feel the need to pass stool even you just finish bowel movement? Straining: Do you need to push hard during bowel movement and only little stool comes out? Derma: Rash questions:Description(Can you tell me more about your rash?),Onset( when did it start?) Progression(Is the rash progressing?From where to where?) Photosensitivity: is your skin sensitive to sunlight?

Ob/Gyn:Primary/secondary Amenorrhea: Did you have mensural period before? Galactorrhea:Is there any nipple dischage? Hirsutism/Virilization:Did you notice any increase of body hair? is there any voice change? Douching: Did you use any advice to rinse your vagina? Others: Impotence severity: On a scale of 1-6 ,as 6 is adequate for penetration, how are you going to rate your problem. Secretions Questions(Vomitus/Diarrhea/Urine/Vaginal discharge/vaginal bleeding) :Content /Color/Blood(and mucous in stool)/amount(A cupful, a teaspoon, or a tablespoon?) /odor Medication questions:Dosage, compliance, side effect, Control(HTN,DM), last HbA1C(DM) Insulin:Site of injection, Insulin injector, Compliance with insulin, Schedule of insulin Common Counseling Smoking 1.damage your heart and your lungs. 2.can use Nicotine patches or Gum to help reduce those withdrawal symptoms 3.we even have a professional team to help you deal with it better. 4. Feel free to contact me anytime if you decide to quit. Alcohol 1.Excess alcohol consumption raises your risk of high blood pressure, liver problem, car accidents 2.Avoid drinking before or when driving 3.We have a professional team that can help you deal with it better. 4.Feel free to contact me anytime if you decide to quit. Unsafe sex: 1.use condoms regularly in order to reduce sexual transmitted disease 2. watch for unusual discharge, sores, redness, or growths in genital area, or pain while urinating. 3.blood test for HIV DM: 1. Follow regular exercise and diet instructions that will be provided to you 2. make a habit of using soft footwear whenever you walk 3. Be regular in blood-sugar monitoring so that dose adjustments can be done on time. HTH: 1.regular exercise 2. reduction of weight 3. limiting salt 4. take regular health maintenance examinations to help control your blood pressure. Hyperlipedemia:1.take the medicine regularly, 2.low fat, low salt diet, prevent things like egg yolk and fatty meat. 3.do some moderate exercise 30 min a day Overweight:

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

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

SLE related :oral ulcer, photosensitivity, Rash, CNS(seizure/limbs weakness,headache), system review problems Ob/Gyn:Menopause symptoms:Common :Hot flashes, Urinary irritaive symptoms, joint pain Sex symptoms:vaginal itchness/dryness, pain when intercose/low libido, Others:mood change, Sleep distubance Others:Constutional: Fever/Chills, Night sweats, Weight loss, fatigue, loss appetite System review:Fever/Chills,CNS: Headache,dizziness Chest:Chest pain, Short of breath, cough, Abdomen:abdominal pain, Nausea/vomitting, Diarrhea/Constipation, Urinary: any urinary problems Extremties:weakness /numbness Pituitary tumor:Headache/decrease vision, Galactorrhea/Amenorrhea, Anorexia nervosa: Amenorrhea, Cold intolerance, body image CNS symptoms after trauma:Head and neck: Headache(ask with Nausea/vomitting),stiff neck Memory loss (Change in personality,Confusion) ENT:Change in vision, Discharge from the ears/mouth/nose , Dizziness Limbs:Weakness or numbness in the extremities, shaking (convulsions) Seizure: bit tongue, confusion after regain consciousness, incotinence during seizure, body shaking Jaundice: skin/urine/stool color change, pruritis,constutional symptoms Colon cancer:Decrease in diameter of stool, bowel habit /stool color changes,straining/ bloating/ tenesmus TB:cough, SOB, hemoptysis, pleuritic chest pain, constitutional symptoms Mononucleosis:sore throat, rash, jaundice, abdominal pain, swelling glands Pregnancy symptoms:GI:Abdominal pain, Nausea/vomiting, Bowel habits change, Urine:Urinary habits change (frequent urination) Constitutional:Fever, Fatigue, Appetite changes,Weight changes Others:Backpain/headache, Shortness of breath, Skin changes, vaginal bleeding, Pulmonary embolism: Shortness of breath, Chest pain, Fever DM complication:Visual: Visual change, Heart:chest pain, palpitation , Pulmonary:Cough, SOB, CNS: Headache, dizziness, , Abd:nausea/vomitting Urinary:urinary change( polyuria, dysuria, hematuria), impotence Ext:limbs weakness/sensational change, foot infection DM constitutional symptoms:Urinary habit changes(frequent urination) Abnormal thirst or extreme hunger, Weakness or fatigue, Weight changes, tireness HTN complication:Visual: Visual change, Heart:chest pain, palpitation, edema, Pulmonary:Cough, SOB, CNS: Headache, dizziness, nose bleeding, Urinary:urinary change, impotence Ext:limbs weakness/sensational change ADHD symptoms: cant concentrate, easily distracted, Have trouble sitting still ,moving all the time , talk too much, interupt games/conversation, has trouble waiting his turn. has trouble enjoy activities quietly, Not seem to listen when spoken to Mnemonic:MS.WC(Used in Fatigue/Weight gain/Weight loss/amenorrhea/Confusion& memory loss/depression ) Mood change(if depressed asked FACE SLIPS and abuse) Sleep/snore/Stress/Support Weight/appetite change(if low ask Oncology symptoms) Cold/heat intolerence(if yes ask the other hypothyroid/hyperthyroid symptoms),

Physical Exam Asbefore start:I will do some examinations on you, is that Ok? #HEENT: Head: Palpation::I need to press lightly on your head/face Eyes: Inspection: I need to check your eye, can you look up for me Fundoscope(pupil):I will turn off the light and will shine a light and see your pupil Now I am going to see the back of your eyes Visual field:Can you see the finger moving? EOM:Can you follow my finger, dont move your head Ear: Inspection: I need to check your ears Palpation::I need to press on your ear, I need to pull up your ear now. Otoscope: Right now ,I am going to look into your ear. Rinne test: I'm going to put the fork behind your ears, say "now" when the noise stop Weber test:I'm going to put the fork on your forehead, tell me which side it's louder or it's the same? Whisper into ear:can you tell me what you hear? Nose:Inspection: I need to check your nose Palpation on nose and sinus::I need to press on your nose/face Otoscope: Right now ,I am going to look into your nose . Throat: Otoscope: Please stick out your tongue and say, ah. Can you lift your tongue ? Neck: Thyroid:I need to check for swelling glands, I need you to swallow Lymph node:I need to check for swelling glands #Pulmonary exam (plus regular cadiovascular) Anterior Inspection:first, let me look at your chest Palpation:For local tenderness Tactile fremitus:Can you say 99 for me please? Percussion:I am going to tap on your chest (4 points bilateral) Auscultate: I need to listen to your lung now, can you take deep breath through your mouth for me? (3 points bilateral) Posterior Palpation again Tactile fremitus again Percussion again Auscultate again ,(And listen to heart while telling patient breath in normally) Also remember to check hands for for cyanosis or clubbing #Cardiovascular (plus regular pulmonary) Sitting Palpation:I am pressing on your chest to feel your heart->(press on PMI , if chest pain case also palpate for local tenderness) Auscultation:I need to listen to your heart(4 points)->(listen to posterior lung while pt's sitting) Lying Neck:JVD:Please look to your left, I need to check your neck (shine light with otoscope,patient lie 45 degree, pull out extension) Carotid bruits:I am going to listen to your neck (use bell) Carotid pulse:I am going to check the pulse on your neck.

Also remember to check Pulse(quickly check radial/popliteal/posterior tibial),and Edema(called swelling) #Abdomen exam Inspection:let me look at your belly Auscultate:let me listen to your belly(2 side and midline) Percussion: I need to tap on your belly(4 quadrate, and liver span if suspect hepatomegaly) Palpation:I am going to press softly/deeply on your belly, is that causing any pain? Do you feel any pain when my hands let go? Liver/spleen palpation:I am checking your Liver/spleen Signs:Murphy sign:Can you breath in for me?(while pressing RUQ, do with Liver palpation) Psoas sign: Can you raise your knee? is that causing any pain? Obturator sign:Is that causing any pain?(flexion and interal rotation of hip) Rovsing sign(will know while LLQ tenderness while pressing) CVA tenderness:I am going to knock on your back, is that causing any pain?(do it with psoas sign) Remember to mention Rectal exam/Pelvic exam at the end #MMSE. Used in non-focal-deficit CNS Cases like Dementia/Delirium/Depression/Delusions/Confusion/ Schizophrenia Begin:I would like to ask you some questions to test your memory and thinking,is that Ok? Orientation:Where are you now? Can you tell me your name? What day is today? Registration :I would like to let you remember 3 words to test your memory, it's red/bicycle/happy, can you repeat after me? Attention/Remote memory: Who's the president of United states? Can you spell "WORLD" backward? Recall:Can you tell me the 3 words I want you to remember? If running out of time, just ask orientation #Neurological exam:(CM RS CM, Can Mom Really Sing Country Music?) Cranial nerves: CN 2: Can u count this? (5 fingers with 1 feet in front) CN3/4/6:Don't move your head, please move your eyes to follow my fingers CN5-Can you clench your teeth like this? Can you close ur eyes and tell me where do you feel the touch. CN 7-Can you smile for me? CN 8- I am going to rub my finger, tell me which side you hear it?Is both side equal? CN 9/10 Can you say ahhh(and look into mouth) CN 12-Can you stick out your tongue? and try to move it left and right? CN 11-Can you do like this? (Shrug your shoulder and press resisting power) Muscle Power : Upper extremities:Can you do like this?Dont let me move you, can you raise your wrist up ..and down, can you spread your finger apart, can you squeeze my fingers real hard? Lower extremities:Can you raise your knee?and down ,Kick the leg out, and bring it back. Can you push your foot down, Reflex: Right now I am going to check your reflexes ,Babinski:I need to tickle your feet. Senses: can you close your eyes, tell me is it sharp or dull,(3 points each limbs) Positional(diabetic):This is up and this is down, tell me which direction I am moving your big toe. Vibration(diabetes):I'm going to put this on your feet, tell me can you feel anything? Cerebellar:FNF:can you put your finger on your nose? and pointed to my fingertip? and back to your nose? Ok, the other hand. (Or can do shine to heel, rapid alternative movement)

Gait:Can you get down and walk to the sink ...and back Romberg+Pronator drift:Can you put your palms up like this and close your eyes. I will protect you from falling down Meningeal sign: Kernig:Please let me know if that hurts (flex the hip+extend the knee) Brudzinski: I am going to lift your head up, please be relaxed.(flex the neck) Dix-Hallpikes test:(if you have time and BPPV is strongly suspected):Head extends looking 30 degree left and lie down see if there's any vertigo, and sit up wait 20 secs do it at the right side. #Joint exam(IPRPMRS,Interesting People Rarely Persisently Mention Routine Subjects) Inspection:I am going to look at your feet/shoulder/hands Palpation:Is that causing any pain?(check for tenderness, joint effusion) start with the painless side ROM:II am going to move your joint to see if theres limitation Pulse:I am going to check your pulse Muscle strength:Do this, dont let me move you Reflexs:I need to tap on your arm/legs Sensory:Light :Can you feel this? Does it feel the same?(Sharp/Dull: This is sharp and this is dull, now close your eyes, tell me it's sharp or dull?) Shoulder pain: impingement symdrom (bring the arms across the chest or bring the arm around), Rotator cuff injury(drop arm test) Wrist pain: +Tinel sign+Phalen test+Adson test Tinel: I am going to tap on your wrist,(and extend the wrist while tapping) Phalen:Can you hold your hands like this? Is there's any numbness or pain? Lower back pain:+Gait+SLR+Hip exam SLR: I am going to raise your legs, is that causing any pain(raise extended legs+ dorxiflex the foot for more than 60 degree) Knee pain: Anterior/posterior drawer+Medial/lateral collateral ligament, McMurray test,Patella McMurray test:I am going to check (external rotate and extend the knee->then internal rotate and flexed the knee) Anterior/posterior drawer test:I am going to check knee tendon(put thumbs on tibal plateau, hands holds tibia and push anterior then posterior) Medial/lateral collateral ligament: is that causing any pain? (and bring the legs inward and outward) #When to order breast, pelvic, rectal, genital exam? Constipation/diarrhea, Lower abdominal pain: rectal exam, pelvic Amenorrhea: breast exam, pelvic Erectile dysfunction, Urinary problem,Hematuria: genital, rectal Pregnancy, viginal bleeding/discharge, dyspareunia, sexual abuse: pelvic Nausea/vomitting, low back pain: rectal exam Bed wetting: genital exam #Rinne/Weber test Normal:Rinne both ears AC>BC ,Weber without lateralization Rinne both ears AC>BC Rinne left BC>AC Rinne right BC>AC Weber lateralizes left Sensorineural loss in right Conductive loss in left conductive+sensorineural loss in right Weber lateralizes right Sensorineural loss in left Conductive +sensorineural loss in left Conductive loss in right

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

In detail depends on what is examined(red:abnormal PE CSA people can make) no acute distress.(anxious and in acute distress, in severe pain) VS: WNL(except T:105F) Head: Inspection:NC/AT, Palpation:no tenderness (tenderness over right temporal area) Eyes: Inspection: EOMI, no icteric sclera,no pale conjuntiva. (Lid lag nystagmus, visual loss,) Fundoscope: PERRLA , normal fundus.(photophobia) Ears Observation: no discharge Palpation:no tenderness Otoscope:no cerumen, TMs with light reflex, no sign of infection Weber Rinne:Weber test no lateralization, Rinne test AC>BC both side.(Decreasing hear ing acuity on left ear, Weber test lateraization to left, Rinne test AC>BC on left side) Nose: No nasal congestion/discharge. Throat: No tonsillar erythema, exudates, or swelling. (enlarged tonsil) Mouth: no lesions, Moist MM, good dentition Neck : Inspection:no JVD LAD palpation: Supple, no LAD , Thyroid palpation: normal thyroid (thyroid bruits) Carotid auscultation/pulse: carotid no bruits, 2+ pulse (carotid bruits) Chest: Inspection:(bruises)

Palpation: No tenderness(ribs tenderness) Percussion:Clear to percussion Bilateral tactile fremitus WNL.(Increase tactile fremitus) Auscultation:Clear Breathing sound (wheezing, decrease breathing sound) Heart: PMI not displaced, RRR; normal S1/S2; no murmur,(rubs, gallops) Abdomen: Inspection:(C-section scar) Auscultation:+BS Palpation: Soft, ND/NT ,no Organomegaly, no masses ( tenderness, guarding, rebound, CVA tendernes, Psoas+,murphy+,Rovsing+, obturator+) Neuro: AAOx3(not oriented to time) Able to spell backward (cant spell backwards) Distant memories normal, 3/3 registration and recall x3(cant recall 3 subjects) CN2-12 intact. Motor 5/5 throughout.(motor 5/5 throughout except 3/5 in right arm) DTRs: 2/2 throughout, (DTR:3+ right,1+ left, brisk reflexs) Babinski (-) bilateral. ( babinski+) Intact to light touch. (impaired to light touch on left upper/lower ext) finger to nose normal(post-pointing and intentional tremor) Romberg (-) ,(romberg+) Gait: normal. (bradykinetic, takes small steps, walk with back slightly bend forward) Extremities: Inspection:No clubbing, cyanosis, edema.(cyanosis, tremor on outstreched finger tips, right side swollen than left side, ulcer, pigmentation,erythema) Palpation:(right side is warmer compared to left, pitting edema,tendrness) ROM:normal(restricted ROM on flexion/entension of left knee compared to right knee) Pulse: Bil 2+ perepheral pulses (doralis pedis/posterior tibialis/brachial/redial) Other:(Homers sign+,patrick test+, tinel sign, rotator cuff ,impingement sign+, ) Back: Inspection:No deformities or bruises(deformities or bruises) Palpation:No tenderness(tenderness) ROM normal(Limited anterior ROM) SLRT(-) (SLRT+) Skin: no rash, no lesion(redness, jaundice, spiders/telangiectasias/palmar erythema) Useful scales: Reexes (04), with 0 being completely are exic: 1: Hypore exia. 2: Normal re exes. 3: Hyperre exia. 4: Hyperre exia plus clonus (test the ankle and the knee). Strength (05), with 0 representing an inability to move the limb: 1: Can move limb (wiggle toes). 2: Can lift limb against gravity. 3: Can lift limb with one- nger resistance from the examiner. 4: Can lift limb with two- nger resistance from the examiner. 5: Has full strength. Pulses (04), with 0 representing pulselessness: 1: Weak pulse. 2: Regular pulse.

3: Increased pulse. 4: Pounding pulse #Normal MSE(Only write when you have time) Appears well groomed Mood/Affect is euthymic. Not hostile,cooperative AAOx3 able to spell backward (or 5/5 on serial 7s. ) Distant memories normal, 3/3 registration, 3/3 recall x3 Speech is fluid and goal directed No abnormal perceptions No suicidal/homicidal idea Judgment/insight intact #Abnormal MSE Apperance:Appears: (well groomed, disheveled, or unkempt). Mood and affect:Mood is (euthymic, depressed, euphoric, angry, anxious ,apathetic). Affect is consistent with mood. Behavior: (cooperative, uncooperative, hostile, guarded, suspicious, regressed, Inattentive, poor eye contact) Schizophrenia :catatonia, Stereotypies, Abnormal movements,disorganized behavior Side effects of antipsychotic medication:akathisia, tremor or dystonia Parkinson's disease, dementia or delirium: psychomotor retardation, akinesia or stupor) Neurological disorder: choreiform, athetoid or choreoathetoid movements may indicate a neurological disorder Cognition: (alert, stuporous, or lethargic) and disoriented to person, place or time. Attention and concentration:(able/unable) to spell WORLD backward (or 1/5 on serial 7s. ) Memory: Distant memories normal (impaired), 3/3 registration, 3/3 recall at 3 times. Speech:Speech is fluid and goal directed Mania or anxiety: pressured speech Depression: prolonged speech latency , speak slowly Schizophrenia halting and tangential, Disorganized speech Perceptions: Doesn't have abnormal perceptions ( hallucinations, delusions, or paranoias) Thoughts: Schizophrenia:Delusions of control, passivity experiences, thought withdrawal, thought insertion, thought broadcasting,Poverty of thought,suspicious beliefs ,suicidal/homicidal idea Mania:Flight of ideas Depression: inhibited thinking, depressive beliefs ,fearful beliefs , Poverty of thought,suicidal/homicidal idea Dementia:Poverty of thought, suicidal/homicidal idea Judgment/insight (intact or impaired).

Section 2 Case Dicussion

Introduction #Symptoms Lab test generally ordered Differential diagnosis 1 Differential diagnosis 2>Lab test specifically used in that differential diagnosis Differential diagnosis 3 :commonly seen differential diagnosis History:system related symptoms,other symptoms(Other: commonly forget history) PE: HEENT/neck/chest/CV/P/Abd/Neuro/Ext Counsel: related to specific symptoms #PE Abbrevieation I use in this note : (dont have time for orthostatic vital sign /blood pressure of both arms, don't even bother) CV(Auscultation):CV, CV(Auscultation+Palpation):Full CV Pulmonary(Auscultation): P, Pulmonary(Inspection, Auscultation, Percussion, Palpation):Full P Abdomen(Palpation):abd, Abdomen(Inspection, Auscultation, Percussion, Palpation):Full abd Neuro(Cranial nerve, muscle power, Reflex, Sensory, Cerebellar): Full Neuro Extremities: Ext Gastrointestinal #EPIGASTRIC PAIN Rectal Exam, CBC/electrolytes/AST/ALT/bilirubin/AlkP/Amylase/lipase, CT abdomen, Endoscopy with H pylori testing Pancrease Pancreatitis, Acute / Chronic Pancreatic cancer Gastric Peptic ulcer disease Peptic Ulcer Perforation ->Upright CXR Gastritis Gastric cancer Funtional dyspepsia Gall Bladder Cholecystitis >HIDA scan Vascular Abdominal Aortic Aneurism Mesentery ischemia >ECG History: abdominal symptoms,constitutional symptoms,,LRI ,Jaundice symptoms ,chronic pain, black stools or blood in the stools , early satiety (Others:Abdominal pain relation with food, history of OP/PUD/NSAID use) PE: HEENT(Eye for jaundice,mouth), CV+P, Full Abd(Murphy sign, Liver palpation)

#RUL PAIN: Rectal Exam, CBC/AST/ALT/bilirubin/Alk-P/viral hepatitis serologies, U/S abdomen Gall Bladder Cholecystitis >HIDA scan Bile duct Ascending Cholangitis >MRCP,ERCP,blood culture (rule out sepsis) Choledocholithiasis >MRCP,ERCP Sclerosing Cholangitis >MRCP,ERCP Liver Hepatitis Fitz-Hugh-Curtis Syndrome ->Laparoscopy History:abdominal symptoms,constitutional symptoms,jaundice symptoms (Others:history of gallstone) PE: HEENT(Eye for jaundice,mouth), CV+P, Full Abd(Murphy sign, Liver palpation) #Male has LOWER ABDOMINAL PAIN Pelvic/Rectal exam, CBC/electrolytes, AXR/CT abdomen,U/A+ culture GI Appendicitis Diverticulitis Inflammatory Bowel Disease Uro Nephrolithiasis UTI #Young female with LOWER ABDOMINAL PAIN Pelvic/Rectal exam, CBC/ESR, urine hcG/ UA/culture, CT abdomen/U/S pelvis GI Appendicitis Uro Nephrolithiasis UTI Gyn Endometriosis >laparoscopy PID > cervical culture Ovarian Torsion >Doppler U/S pelvis, laparoscopy Ruptured Ovarian Cyst Ob Spontaneous Abortion Ectopic pregnancy History:Urinary infection/irritation symptoms , abdominal symptoms,constitutional symptoms,Weight change,,Vaginal spotting/discharge,heartburn (Others:STDs, history of OP/stone, LMP, detail ob/gyn history) PE:No HEENT ,CV+P+CVA ,Full Abd(Psoas, Obturator, Rovsing),ext

#LUL PAIN Rectal Exam, CBC/electrolytes, CXR/U/S abdomen/CT abdomen, Splenic Splenic Rupture Splenic Infarction Others: Pneumonia Kidney stone Rib fracture #CRAMPING ABDOMINAL PAIN Pelvic/Rectal exam, CBC/electrolytes, AXR/CT abdomen Mechanical Intestinal obstruction >Lactate, ABG Hernia Volvulus of the bowel Small Bowel or Colon Cancer Functiional Mesenteric Ischemia / Infarction >Mesentetic angiography leus Irritable Bowel Syndrome Infection Gastroenteritis Food Poisoning #Acute Diarrhea Rectal exam, CBC/electrolytes, stool(leucocyte, culture, parasite antigen), AXR Infection Food poisoning Pseudomembranous colitis >C difficile toxin Travelers Diarrhea Infectious diarrhea #CHRONIC DIARRHEA Rectal exam, CBC/electrolytes/TSH, stool(leucocyte, parasite antigen, osmolarity, fat), AXR, colonscopy/barium enema Diarrhea+ constipation Inflammatory Bowel Disease >small bowel series for chohn's disease, CT abdomen/pelvis Irritable Bowel Syndrome Colorectal cancer >CT abdomen/pelvis Diverticulitis >CT abdomen/pelvis Infection Infectious diarrhea Whipple's disease Bowel wall Lactose intolerance >hydrogen breath test Celiac Disease Carcinoid >urine 5-HIAA, CT chest/abdomen Small bowel lymphoma Endocrine+Exocrine Hyperthyroidism >TSH Chronic Pancreatitis Medication

Laxative abuse History:hyperthyroid/ URI symptoms /colon cancer symptoms, abdominal symptoms,constitutional symptoms,Weight change, cough (Others: diet/fluid intake/specific food related, HIV risk factor, mucous in stool history of OP/pancrease disease, stress for irritable bowel, ill contact/travel ) PE:HEENT(eyes, mouth for dry oral mucosa),Neck(thyroid), CV+P, Full abd, Ext(edema) #Constipation Rectal exam, CBC/electrolytes/TSH , urine toxicology, FOBT, CT abdomen/ pelvis Only constipation Depression Substance Abuse (Heroin) Hypothyroidism Low Fiber Diet Diarrhea+ constipation Inflammatory Bowel Disease Irritable Bowel Syndrome >small bowel series, colonscopy Colorectal cancer >CEA/LFT, barium enema, colonscopy Diverticulitis History:hypothyroid /colon cancer symptoms, abdominal symptoms,constitutional symptoms,Weight change, pain when defecation, colonscope (Others: history of OP, heroin, mood for depression) PE:HEENT(eyes, mouth for dry oral mucosa),Neck(thyroid), CV+P, Full abd, Ext(edema) # NAUSEA / VOMITING CBC/electrolytes, urine hCG, U/A, XR abdomen, GI DM gastroparesis >sugar Gastritis bowel obstruction GERD Other inflamation Peritoneal irritation(PID, cholecystitis, appendicitis, pyelonephritis, pancreatitis) UTI >urine culture Pregnancy Intracranial lesion >Brain MRI Metabolic Hypercalcemia DKA drug induced # NAUSEA / VOMITING with headache CBC/electrolytes/ESR, MRI/CT brain, ECG, LP if no mass effect Intracranial tumor Meningitis/Encephalitis SAH/EDH/SDH Migrain, complicated stroke/TIA

History: Urinary infection/irritation symptoms,CNS (headache/stiffneck, vertigo, focal numbness), abdominal symptoms,constitutional symptoms,Weight change,chest pain, vagainal discharge (others:sick contact, related meal, LMP for pregnancy,diet/fluid intake) PE:HEENT(fundoscope, mouth for dry mucosa), CV+P,Full abd, ext #BLOOD IN STOOLS Rectal exam, CBC/PT/PTT/CEA, CT pelvis/abdomen, barium enema/ colonscopy, Anal Proctitis Anal fissure Hemorrhoids Colon inflammation Infectious colitis inflammatory bowel disease Tumor Colorectal Cancer >AST/ALT/alk-p/bilirumin (for metastasis) Vascular Angiodysplasia Ischemic Bowel Disease Other Upper GI Bleeding Diverticulosis History;colon cancer symptoms, abdominal symptoms,constitutional symptoms,Weight change,mucous in stool, blood and BM relationship, rectal pain, eye lesion/skin lesion/joint pain(for IBS), mucous, blood relationship with stool (Others: bleeding duration, wafarin use, history of atherosclerotic vascular disease/ easy bleeding, diet) PE:HEENT(eye for anemia,mouth), CV+P ,Full Abd,ext #UPPER GI BLEEDING Rectal exam , CBC/Electrolytes, AST/ALT/bilirubin/Alk-P, stool(FOBT), endoscopy Esophegeal Mallory Weiss tear Esophageal Varices Esophagitis Gastric Bleeding peptic Ulcer Gastritis Gastric Cancer >barium sawallow, CT abd History:Jaundice symptoms, abdominal symptoms,constitutional symptoms,Weight change,nosebleed, stool color change, chronic pain, heartburn (Others: symptoms/alcohol before bleeding, history of OP/PUD/liver disease/easy bleeding/trauma, appetite,medication like wafarin/NSAIDs, duration of bleeding, frank blood or coffee ground) PE:HEENT(eye for anemia ,nose, mouth), Neck(LN), CV+P, Full abd, Ext(observation)

#JAUNDICE AST/ALT/bilirubin/alk-p/viral hepatitis serologies/PT/PTT , U/S abdomen,CT abdomen Hepatitis Infectious hepatitis Alcoholic hepatitis Drug induced hepatitis >acetaminophen level infectious mononucleosis Metabolic Wilson's disease Hemochromatosis Obstruction: Primary biliary cirrhosis >ERCP/MRCP Choledocholithiasis >ERCP/MRCP Malignancy (cholangiocarcinoma, pancreatic cancer, carcinoma of ampulla) >ERCP/MRCP Hemolytic Hemolytic jaundice History:Jaundice symptoms,infectiou mononucleosis symptoms, abdominal symptoms,constitutional symptoms,Weight change, bleeding tendencies (Others: blood transfusion,hepatitis history, raw food, tarvel) PE:HEENT(Eye),CV+P (look for spider nevi, cutaneous telangiectasis), Full Abd(Murphy sign, Liver palpation,ascites), Ext(asterixis, palmer erythema) #DYSPHAGIA CBC/electrolytes, CXR, Barium swallow/endoscopy Oropharyngeal dysphagia:(more on liquid) Neuromuscular (CVA, Parkinsonism, multiple sclerosis, ALS ) Mechanical obstruction (Zenker diverticulum, thyromegaly) Skeletal muscle disorders (myasthenia gravis, muscular dystrophies, polymyositis) Esophageal dysphagia(more on solid) Esophageal Cancer >CT chest Esophageal Stricture Mitral Valve Stenosis Plummer Vinson Syndrome >serum iron, ferritin, TIBC Esophagitis ->HIV antibody and CD4 count (for high risk HIV) GERD ->PH monitoring Both(liquid and fluid) achalasia ->esophageal manometry Systemic sclerosis ->esophageal manometry History: abdominal symptoms,constitutional symptoms,Weight change,heart burns, painful swollowing(odynophagia), drooling, color change in finger, choking sensation or regurgitation/aspiration,weakness of the arms or legs,SOB (Others: HIV risk factors, dysphagia on fluid/solid food, where the food stuck ) PE: HEENT(nose, mouth,eye for anemia), Neck(LN,thyroid), CV+P, Full abd, Ext(scleroderma, raynoid phenomenum)

EYES and ENT #Blurred vision (CBC, blood glucose/HbA1C/lipid, U/A ,Doppler of carotids) Diabetic retinopathy Hypertensive retinopathy Cataracts ->slip lamp Glaucoma >tomoometry Macular degeneration History:DM constitutional symptoms, eye symptoms PE:HEENT(fundoscope), Neck(bruit), Neuro(cranial nerve,motor, sensory), CV #SORE THROAT CBC+perepheral smear/LFT, Throat swab(culture and ASLO), Monospot test, HIV antibody/viral load/CD4 Common Infectious Mononucleosis >anti-EBV antibody Viral or Bacterial Pharyngitis Uncommon Acute HIV Infection Hepatitis Mycoplasma pneumonia > mycoplasma IgM Secondary Syphilis >VDRL/RPR History:URI+LRI +constitutional symptoms ,mononucleosis symptoms, joint pain ,vaginal discharge(Others:ill contact) PE:HEENT(eye for jaundice, Nose,mouth for oral thrush/tonsillar exudate,sinus), Neck(LN) CV+P, Full abd(organomegaly), Ext(rash) Counsel:Infectious mononucleosis suggest no strenuous sport #Lose of hearing VDRL/RPR, CThead, Audiometry/Tympanography, BAEPs(Brain stem auditory evoked potentials) conduction loss Cerumen impaction Foreign body Tympanic membrane perforation Cholesteatoma Otitis media with effusion Otosclerosis Tumor in middle ear/ear canal Sensorineural loss Mnires disease Ototoxicity Presbycusis Acoustic neuroma Cochlear nerve damage: History:Ear/CNS symptoms (Headache, weakness/sensational change, trauma) (Others: noise expose,social impact)

(Loud Foreign Jazz): Exposure to loud noises? Insertion of foreign body? Do words sound jumbled or distorted? Is hearing lost for all sounds or for anything specic? Can you locate the source of sound? Do you have any problems understanding speech? Dizziness/Vertigo:Do you feel like spinning is around you or it's inside? PE:HEENT(nose, mouth ,sinuses,otoscopy/Rinne/Weber+whisper test ),Neck(carotid bruit) Full neuro, (CV) #Hoarseness CBC/TSH, laryngoscopy+biopsy, CXR Vocal nodules/ polyps Laryngitis Leukoplakia Lung cancer/ laryngeal cancer GERD > PH monitoring Hypothyroidism Amyloidosis Parkinsons disease/stroke Trauma History:Chest symptoms, hypothyroid symptoms,constitutional symptoms Heartburns, dysphagia, swelling glands,postnasal dripping(Others: Activity/when get worse?environmental exposure) PE:HEENT(Nose/mouth), Neck(Thyroid, LN), CV+P Counselling: 1.Voice rest 2.smoking cessation 3.Voice therapy in singer RESPIRATORY TRACT #SOBCBC, Gram stain and culture (if with sputum), PPD, CXR/CT chest, serum Mycoplasma IgM, Urine Legionella antigen, ABG (if SOB) Treachea Chronic Bronchitis >PFT Asthma >PFT+peak flow measurement Aveolar/Interstitium Pneumonia(typical and atypical) Interstitial Lung Disease >PFT Heart: Congestive Heart Failure >U/S heart, ECG,BNP Cardiac Valvular disease >U/S heart, ECG Destructive Tuberculosis >bronchoscopy, Acid fast stain Lung Cancer >bronchoscopy Phychologic Anxiety and panic attacks #COUGH (add SOB causes SOB causes)CBC, Gram stain and culture (if with sputum), PPD, CXR/CT chest, serum Mycoplasma IgM, Urine Legionella antigen, ABG (if SOB)

URI Post nasal drip URI associated (post infectious) GI GERD Exposure Occupation exposure Secondary to ACEI use History:Respiratory, constitutioal symptoms,Postnatal drips, heartburns, night SOB,orthopnea leg pain/swelling,LOC (Others: TB/animal/chemical/sick people exposure, Last PPD, family history of blood clots and heart problems, MI and immobilization) PE:HEENT(eye,nose,mouth,sinus),Neck(LN,JVP, carotid pulse/bruits) full CV+Full P, Ext(clubbing/cyanosis, edema, calf muscle tenderness, pulses) #Hemoptysis CBC/PT/PT, sputum Gram stain/AFB/culture/cytology, CXR/CT chest, PPD Bronchiectasis Acute or chronic bronchitis Pneumonia Bronchogenic carcinoma >bronchoscopy Lung abscess Tuberculosis Connective tissue diseases (Wegeners disease, Goodpastures, Lupus) ->ESR, BUN/Cre, c-anca Pulmonary embolism >V/Q scan, CT chest with contrast, Doppler U/S legs, D-dimer History: Respiratory, constitutioal symptoms ,skin rash (Others:TB contact, Family history of coagulation) PE:HEENT(eye,nose,mouth,sinus),Neck(LN,JVP, carotid pulse/bruits) full CV+Full P, Ext(clubbing/cyanosis, edema, calf muscle tenderness, pulses) #Asthma drug refill:CBC/aspergillus serology, CXR, PFT, skin tests Bronchial asthma COPD bronchopulmonary aspergillosiss sinusitis atypital GERD History:Respiratory, constitutioal symptoms,medication problem, asthma control(regular activity /exercise/exccessive coughing/emergency), precititation, PE:HEENT(nose,mouth,sinus),Neck(LN,JVP) full CV+Full P, Ext(clubbing/cyanosis, edema) Counsel: 1.Most common cause of recurrence of asthma symptoms is interruption of controller medications. 2.You should take it every day without missing a single dose. 3.see you again in about 3 months for a checkup.

Cardiovascular #CHEST PAIN CBC/electrolytes, CPK-MB/troponin I, ECG, CXR, ABG(if SOB) Heart(and aorta) Angina >cardiac cathterization, exercise stress test Myocardial Infarction (MI) >cardiac cathterization Pericarditis Aortic Dissection >TEE,aortic angiography, MRI/MRA-aorta Pulmonary Pulmonary embolism >V/Q scan, CT chest with contrast, Doppler U/S legs, D-dimer Pulmonary Infarction Sickle Cell Disease >V/Q scan, CT chest with contrast Pneumothorax Pneumonia GI Esophageal Spasm Esophageal Rupture Esophagitis GERD >Endoscopy, PH monitoring, barium swallow Chest wall Muscle Strain Costochondritis Rib frcature #If young adults+TSH/CBC/troponin/CK-MB/CPK, EKG,Urine VMA, CXR Panic disorder Hyperthyroidism Pheochromocytoma >Urine VMA Hyperventilation syndrome History:CV,LRI symptoms, noctural dyspnea, sweating, leg swelling/pain, dizzy, sense of terror, syncope , headache (Others: MI and immobilization) PE:Neck(JVD, carotid pulse/bruit),Full CV+Full P, Full abd, Ext(edema, perepheral pusle) # Sickle cell anemia pt c/o chest pain : History:CV symptoms,Pulmonary symptoms, pain in joint, dehydration, trauma PE:HEENT:(eye, mouth), Neck(LN), full P+full CV, Ext Counsel: 1.avoid dehydration 2.contact doctor if theres fever and short of breath 3.Flu shot each year #PALPITATIONS CBC/electrolytes/glucose/TSH, ECG, Holter monitor Heart Angina Cardiac Arrhythmias Endocrine Hypoglycemia Hyperthyroidism >FT4 Pheochromocytoma >MRI abdomen, VMA Carcinoid ->CT chest/abdomen ,5-HIAA Phycological

GAD (Generalized Anxiety Disorder) Hyperventilation episodes Panic attacks History:CV, hyperthyroid /CNS symptoms (lightheadedness, headache, LOC,sweating) (Others: feeling/activity doing while palpitation, history of bleeding/anemia/heart heasese) PE:HEENT(exophthalmos, lid retraction, lid lag)Neck(thyroid palpation/bruit), full CV,Ext(tremor, edema) Neurology #DIZZINESS CBC/electrolytes, MRI brain audiogram(if not hearing well) CNS TIA or stroke Brain Stem or Cerebellar Tumor Acoustic Neuroma Vertebrobasilar Insufficiency Heart Coronary artery disease Congestive heart failure Arrhythmias Others Orthostatic Hypotension >Orthostatic vital sign, BUN/Cre Autonomic dysfunction Hypoglycemia #Vertigo Dix-hallpike maneuver, CBC/electrolytes, ENG(electronystagmography), MRI/MRA brain ,audiogram/BAEP(if not hearing well) Meniere Disease >VDRL/RPR Vestibular Neuronitis Labyrinthitis Benign Positional Vertigo Vertebrobasilar Insufficiency History:CNS,URI/LRI/Ear/Abdomen symptoms, Falls, palpitation(Others: history of neck injury/vasular disease, any warning sign ) PE:HEENT(eye for nystagmus ,mouth sinus,otoscope/Rinne+weber+whisper test sinuses if hearing loss) ,Neck(carotid bruit) Full Neuro ,(CV) #SUDDEN HEADACHE CBC/ESR, CT head no contrast/MRI brain, LP analysis Brain inflammation Encephalitis Meningitis >LP analysis with gram stain, PCR, culture Temporal Arteritis >temporal artery biopsy Vascular Acute hypertension Carotid/Vertebral artery dissection >doppler U/S carotid Intracranial Venous Thrombosis Intracranial/Subarachnoid Hemorrhage >PT/PTT,MRA brain Eyes+ENT mechanical

Sinusitis >CT sinus Phychiatric Caffeine or analgesic withdrawal #Chronic headache CBC/ESR, CT head no contrast/MRI brain, LP CSF-analysis Common Cluster headache Migraine Tension headache Temporal Arteritis >temporal artery biopsy Neoplasm Intracranial Neoplasm Pseudotumor Cerebri >urine hCG, LP analysis+opening pressure Eyes+ENT mechanical Refractive errors Sinusitis >CT sinus Trigeminal Neuralgia TMJ Dysfunction Phychiatric Depression History:CNS,URI symptoms, Aura, cough, tearing, neck pain, pain in jaw (Others:timing (time of the day, sleeping), mense relationship, OCP use) PE:HEENT:(Palpation of temporal/sinuses/TMJ, nose, mouth),Neck(palpation to shoulder, carotid bruit), Neuro(CN, Muscle power, DTR,Brudzinski/kernig) #LOSS OF CONSCIOUSNESS CBC/electrolytes/glucose, CT head/Doppler U/S carotid, ECG+Holter monitor, CNS: Stroke Seizure >EEG,MRI brain, prolactin SAH/SDH/EDH >LP CSF analysis Heart+ Vascular Cardiac Arrhythmia > U/S heart MI >U/S heart Aortic Stenosis >U/S heart Pulmonary Embolism >V/Q scan, CT chest with contrast, Doppler U/S legs, D-dimer Vasovagal Syncope Endocrine Drug-induced Orthostatic Hypotension >orthostatic vital sign Hypoglycemia Substance Abuse / Overdose >urine toxicology History:CV/CNS/ seizure symptoms, unusual sensation(palpitation, sounds, light,nausea) before falls (Others: LOC before or after the fall, history of heart disease/seizure/stroke/ PE risk factor, what happened/activity before the LOC) PE:Full neuro, HEENT(head/mouth),Neck(Carotid pulse/bruit/thyroid),CV Counsel: 1.not drive again until we are sure what caused you to loss consciousness, #NUMBNESS & WEAKNESS

UMN:Intracranial CNS Vasculitis Intracranial tumor >MRI brain Seizure /Todds Paralysis >EEG Stroke /TIA >MRI/CT brain ,ECG, Doppler carotid, U/S heart, PT/PTT SDH/EDH >Brain CT Migraine, complicated UMN:Spinal Tumor in the Vertebral Canal >MRI spine Neurosyphilis >RPR/VDRL Syringomyelia >MRI spine ALS >EMG/NCV, CT/MRI cervical spine Horners Syndrome MS >VEP(visual evoked potential), CSF analysis, MRI brain LMN+muscular Peripheral Neuropathy (Diabetic/Alcoholic/B12 Deficiency) Polymyositis GBS >CSF analysis, EMG/NCV Myasthenia Gravis >Tensilon test, single fiber EMG,Ach antibody, chest CT(for thymoma) Others: Conversion Disorder Hyperventilation Hypoglycemia Hypocalcemia History:CNS, constitutional symptoms (Others: distribution, history of DM/HTN/vasular disease) PE:Neuro(Muscle power, sensation, DTR), Ext(pulse),Neck(Carotid bruit) #Frequent Falls CBC/electrolytes, MRI brain,EEG,EKG Brain Cerebellar disease Seizure Brain tumors Parkinsons disease Others: Diabetic neuropathy Fractured hip Vertigo History:Neurological symptoms, seizure, palpitation, dizziness (Others:injury associated with fall,los e consciousness before or after your fall? any difference in the way you walk? living condition and supporting systems) #Seizure CBC/electrolytes/glucose/prolactin, CT head/MRI brain, EEG, LP with CSF analysis, urine toxicology CNS Brain tumor encephalitis/meningitis

SAH/SDH/EDH Endocrine hypoglycemia Alcohol withdrawal/ Substance Abuse Tremor: TSH, heavy metal screen, MRI brain CNS lesion Parkinsons disease Midbrain lesion Wilsons disease >ceruloplamin, slit lamp examination, AST/ALT, 24 hr urine copper, liver biopsy cerebellar lesion Others: Drug-induced tremor Essential tremor Physiologic tremor Psychogenic tremor Hyperthyroidism PE:Full neuro, Neck:(thyroid,carotid bruit), #CONFUSION/MEMORY LOSS CBC/B12/TSH/RPR/electrolytes/Ca/glucose/BUN/cre, CT head/MRI brain ,EEG, LP Dementia Alzheimers Disease Lewy Body Dementia Vascular Dementia Pick's dementia Normal Pressure Hydrocephalus >LP CSF analysis+opening pressure Huntinton's disease Progressive supranuclear palsy Depression(pseudo-dementia) Intracranial lesion Intracranial Tumor Chronic Subdural hematoma Infection cause Creutzfeldt-Jakob Dis. >brain biopsy Neurosyphilis Metabolic cause Hypoglycemia Hypothyroidism Wernickes Encephalopathy B12 Deficiency >serum B12 Others: Delirium History:MS.WC ,CNS symptoms ,ADL, IADL incotinence ,gait disturbance, Things hard to remember

ADLs(DEATH)+IADLs(SHAFT) Begin with :Is there anything in the daily living you can't do by yourself? Dressing: Do you have problem wearing clothes? Eating: Do you have problem eating by yourself? (Can ask alone with F) Ambulation: Do you have problem getting in and out of bed? Toileting: Do you have problem using toliet? Hygiene: Do you have problem bathing? Shopping: Do you have problem shopping? Housekeeping: Do you have problem keeping your house clean? Accounting: Do you have problems managing money? (Food preparation: Do you have problem preparing food?) (Transportation:Do you have any problem driving a car or taking a bus?) PE:Full neuro(+MMSE), HEENT(pupils, fundus),Neck:(thyroid,carotid bruit) Counsel: 1. permission to speak with family members about social support and safety at home. 2. excellent social worker managing daily activities and future living plans 3.Explain the necessity to take medicine regularly Urology #HEMATURIA Genitourinary exam/rectal exam, BUN/cre/PSA/CBC/PT/PTT, UA/cytology, CT abdomen/pelvis, U/S renal/transrectal, IVP HITTERS Hemotalogy-coagulation Infection Trauma Tumor(Bladder Cancer/RCC/Prostate Cancer) Exercise Renal disorders(AGN, PCKD) Stone(Nephrolithiasis ) History: urinary Irritative+infection symptoms +Constitutional, sore throat ,jaundice(Others:history of vigorous exercise/trauma/stone/cancer/hepatitis/easy bleeding, quantity of unine, food like berries/colored candy/beets) PE:HEENT(eye for anemia,mouth),CV, full abd(+CVA tenderness), Ext(inspection, palpation for inguinal LN) #obstructive symptoms Rectal exam, CBC/BUN/Cre/PSA, UA+culture,U/S prostate Prostate BPH Prostate Cancer >CT pelvis, IVP Bladder Bladder Cancer Bladder Stones Renal

Renal Cell Carcinoma Nephrolithiasis History: urinary Irritative+infection, obstructive symptoms,+Constitutional back pain, trauma,hematuria (Others:history of stone/cancer/BPH/urinary tract instrumentation) PE:full abd(suprapubic percussion for distended bladder), neuro(lower ext Muscle power, sensation, DTR)

#burning urine Genital exam, CBC/BUN/Cre, UA/culture, (Gram stain/culture on urethral discharge if appears), (Chlamydia and gonorrhea PCR if suspected STD) Urethritis, Cystitis, Prostatitis Acute Pyelonephritis >CT abdomen, U/S renal Vaginitis History:rinary Irritative+infection symptoms +Constitutionalpain when intercose, back pain, vaginal discharge, bleeding (Others: STD, history of stone/cancer/UTI/BPH/trauma/urinary tract instrumentation) #Incontinence in female Pelvic exam, Bun/cre, U/S abdomen+post voiding volumn, Urodynamic study, UA+culture Stress incontinence Urge incontinence functional incontinence Overflow incotinence Cystitis History:rinary Irritative+infection symptoms +Constitutional,activity/strong urge before leaking,leaking during sleep weakness/numbness, LBP (Others: affect daily living/relationship, viginal delivery) PE:Full abd +CVA, neuro(motor, DTR,Sensory) Counsel: 1.the outlet of bladder become weak 2.also has to rule out neurological and infection problem 3.Restriction of caffine/alcohol 4.Wearing absorbent pad to avoid embrassing incident #FLANK PAIN Rectal exam, BUN/Cre, UA/urine culture, IVP/CT abdomen/U/S renal Inflammation Glomerulonephritis Pyelonephritis Cancer Renal cell carcinoma Stone Nephrolithiasis

Retroperitoneal lesions #INCREASING URINATION Fasting blood sugar/electrolytes, Urinalysis , Urine and serum osmolality Diabetes mellitus Central diabetes insipidus Nephrogenic diabetes insipidus Psychogenic polydypsia Hypercalcemia History:DM constitutional symptom, urinary obstructive /irritative/ infection symptoms(Others: head trauma, psychiatric problems ) PE:HEENT(oral mucous, fundus),Ext (MP/reflex, sensation ), CV Rheumatology/Musculoskeletal Rheumatology:Ask rheumatology system specific symptoms first(CITRUS HPT) CITRUS HPT:Chest pain/ cough, Insect/tick bite, Trauma/travel, Rash, Ulcer in mouth Stiffness in morning Hair loss, Photosensitivity Temperture cause finger color change #LOW BACK PAIN XR-L spine,MRI L spine ,DEXA scan , Ca/P/Alk-P Muscular Lumbar Muscle Strain Mechanical Disk Herniation Cauda equina syndrome Osteoporosis with vertebral body fracture Degenerative joint disease Lumbar Spinal Stenosis Oncology Tumor in the vertebral canal Pathologic fracture Rheumatology Ankylosing Spondilitis RA Infection osteomyelitis/discitis/epidural abscess Intraabdominal+retroperotoneal pathology Abdominal aortic aneurysm Others Malingering Knee or leg fracture >X ray knee History:constitutional symptoms , urinary/fecal incotinence, weakness/numbness, difficulty urinating (Others: Trauma, history of cancer, urinary tractinfection, DM, renal stone)

PE:Sit: Back(IP,P) Neuro(MRS), HEENT(eye for conjuntivitis) Lie down:Hip exam, SLRT Stand: Anterior ROM by touch toes ,gait including toe and heel walking #Evaluation of OA: History:weakness/numbness, cracking sound, pain elsewhere (Others: what time/activity feel more pain, limitation in walk, LMP for menopause, HRT/calcium supply) Counsel:Regular pain killer, weight reduction, Regular exercise #Heel pain CBC/ESR, XR foot/ankle,Bone scan Rheumatoid factor assey Orthopedeic Plantar fasciitis Achilles tendonitis ankle sprain retrocaneal brusitis tarsal tunnel syndrome Calcaneal periostitis Calcaneal spurs Painful heel pad syndrome Stress fracture Oncology Bone tumors Rheumatology Rheumatoid arthritis Reiter's syndrome Psoriatic arthritis reactive arthritis PE:Ext(Inspection of both feet and ankle in non-weight bearing/weight bearing, PRP ,capillary relling of the toes) Neuro(MRS, include great toe extension) HEENT(eye for conjuntivitis) Counsel:rest for 2-3 days, Ice 30 mins every 4 hours, avoid excessive weight on heel #Knee pain: Knee aspiration and synovial fluid analysis, ANA/anti-dsDNA/RF/uric acid/PT/PTT before aspiration, XR knee Gout Pseudogout OA RA SLE gonorrhea septic arthritis non-gonorrhea septic arthritis reiter > urethal culture PE:Ext(IPRP,Anterior/posterior drawer,Medial/lateral collateral ligament, McMurray test) Neuro(MRS), HEENT(eye for conjunctivitis)

#Unilateral leg pain D-Dimer, CPK,myoglobin, CBC, hypercoagulability study, doppler U/S, CT venography, MRI legs Vascular Deep vein thrombosis superficial venous thrombosis Mechanical baker's cyst rupture Trauma Spasm/sprain Inflammatory myositis cellulitis History:pulmonary embolism symptoms, Legs (Swelling , Injury , Redness, Warmth, Varicose veins) (Others: PE risk factor) PE:Ext(IPRP, including femeral pulse, Homans sign), Neuro(MRS),CV+P(for embolism) #bilateral leg pain: Vascular >doppler U/S, ABI, angiography Thromboangiitis obliterans Arterial insufficiency Deep vein thrombosis Neuro >MRI lower back Lumbar spinal stenosis Diabetic polyneuropathy Lumbosacral Radiculopathy Inflammatory >CPK,aldolase polymyositis Rhambdomyolysis >urine myoglobin, UA inclusion body myositis History;Back pain, pain in the rest, weakness/numbness of legs, fever, trauma, prolonged immobilization , impotence PE:Ext(Pulse, palpation, Homen sign, sensation+ vibration sense, reflex) #multiple joint pain RF, ANA,ESR Psoriatic arthritis Rheumatic arthritis SLE Reiter arthritis Dissemintaed gonorrhea >cervical culture #shoulder pain XR shoulder/arm, MRI shoulder shoulder dislocation fracture of humerus Rotator cuff injury impingement symdrome PE:Ext:(IPRP,impingement symdrom,Rotator cuff injury),Neuro(MRS)

#elbow pain X ray, MRI elbow, bone scan lateral epiconditis stress fracture medial epicondytis elbow subluxation brusitis arthritis #Wrist pain X ray, MRI wrist carpal tunnel syndrome >NCV study Sprain/strain tendinitis brusitis Arthritis With injury Sprain/strain colles fracture smiths fracture History:symptoms worsen with the above head activities, like combing, knee pain with trauma:any noise, unstable, locking of joint, PE:Ext:(IPRP,Tinel sign,Phalen test,Adson test),Neuro(MRS),HEENT(eye for conjuntivitis) carpal tunnel syndrome counsel:1.Take plenty of breaks from activitie 2.Make sure that your keyboard is low enough 3.An occupational therapist can show you ways to ease pain and swelling 4.wear a wrist splint at night while you sleep #Polymyalgia CBC/ESR/CRP/CPK/TSH, EMG (if muscle weakness) Polymyalgia rheumatica Fibromyalgia Polymyositis/dermatomyositis Viral infection Drug induced(ACEI , statin) Rhabdomyolysis Rheumatologic disorders (RA, SLE) >RF, ANA, anti-dsDNA chronic fatigue syndrome Depression Trauma history:Constitutional symptoms, common cold symptoms, Joint pain, weakness/numbness, Headache(for polymyalgia rheumatica associted with temporal headache),Rash (dermatomyositis), trigger points(Fibromyalgia) (Others: limitation of daily life in difficulty going up stairs, getting up from chairs, and raising hands above the head, mood, sleep) PE:HEENT(head palpation, mouth), Neck(thyroid), Neuro(muscle power, DTR, sensory), Ext (palpation for trigger points)

Counselling: 1.Physical therapy 2. Massage therapy 3.Trigger point injection if presents Obstetrics/Gynecology (Ask detailed Ob/Gyn hostory) #DYSPAREUNIA Pelvic exam, cervical cultures+KOH prep+wet amount, U/S pelvic Vagina Vaginismus vaginitis Vulvodynea Atrophic Vaginitis Cervix+Uterus+Abdomen Cervicitis Endometriosis >Laparoscopy PID Others Depression Domestic Abuse Menopause Histrory:Menopause symptoms, vaginal discharge/nipple disscharge itching, rash (Others: Sexual history (sexual desire, History or current sex abuse, lubrication)conflict with partner, stress, Douching, History of endometriosis/ PID and surgery) PE:HEENT(oral), CV+P, Full abd, Ext #VAGINAL BLEEDING pelvic exam,CBC, pap smear, urine hCG, U/S pelvis Pregnancy(young) Ectopic pregnancy >Quantitative serum hCG, transviginal U/S Spontaneous abortion Molar Pregnancy Cervix(midage/young) Cervical Cancer >cervical biopsy+endometrial curettage Cervicitis Cervical Laceration Endometrial(old woman) Endometrial Cancer >endometrial curettage+biopsy Endometrial Hyperplasia >MRI pelvis Abdomen(ovary) Ovarian Torsion Ruptured Ovarian Cysts PID >cervical culture, ESR, CRP Others: DUB >PT/PTT Coagulation Disorder History:GI,constitutional symptoms, vaginal discharge/pain, urinary problem

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

#VAGINAL DISCHARGE Pelvic exam, cervical cultures+KOH prep+wet amount, PH of vaginal fluid, urine culture Bacterial Vaginosis (grey-white fluid foul smelling) Vaginitis Candida (white cottage cheese odorless) Vaginitis Trichomonal (greenish malodorous) Cervicitis (Chlamydia, Gonorrhea) History:GI,urinary tract infection/irritative symptoms, vaginal pain/ buring/ pruritis (Others: history of IUD/OCP/STD) PE:HEENT(oral), CV+P, Full abd, Ext #Hot flashes: History:menopause/ hyperthyroid symptoms, (Others: history of thyroid disease ) PE:Neck(thyroid, LN), CV+P, full abd, Ext(inspection, hyperactive reflexs) Counsel: 1.Hormone replace therapy, but risk of increasing breast cancer so only used in limited time 2.calcium supplement and weight bearing exercise for prevention of osteoporosis #Positive pregnancy test: Breast/pelvic exam/Pap smear/cervical Gonorrhea and chlamydia DNA testing,CBC/glucose/TSH/RPR/rubella igG/HbsAg/HIV antibody, Blood type/Rh/antibody screen, U/S pelvis, UA+culture/ Urine hCG Normal pregnancy Molar pregnancy Ectopic pregnanacy History:vaginal bleeding(Others:sexual history including STD+ Postcoital bleeding, fetal movement, feet swelling Is that planned pregnancy? Want this pregnancy right now,domestic abuse? exposure to cats,rubella immunization,previous heart problems / Blood transfusions,Caffeine used) PE:HEENT(eye for pallor) Neck (thyroid),CV+P, Full abd(and fundal grip) Ext(pigmentation,swelling, edema and varicose veins) Counsel: 1. take regular amount of vitamins, Iron supplementations and nutritious diet. 2.You should also come to prenatal check every 1 month. 3.Run some more blood tests, a Pap smear, and some vaginal cultures, pelvic ultrasound 4.stopping alcohol consumption and avoiding intense exercises and excess caffeine 5.Avoid Cat for parasite #AMENORRHEA pelvic exam, CBC/TSH/FSH/LH, urine hCG, U/S pelvis, MRI brain Endocrine Pituitary Tumor >breast exam/prolactin if prolaactinoma

Sheehan's Syndrome >FT4, ACTH,prolactin, Thyroid Disease >FT4 Ob Pregnancy >pap smear, cervical culture, rubella antibody, HIV/HBV test, RPR/VDRL Gyn(Ovary) PCOS >testosterone/DHEAS Premature Ovarian Failure Menopause >DEXA scan, lipid profile Anovulatory Cycle Mechanical Ashermans Syndrome >Hysteroscopy Others: Anorexia Nervosa >FT4,ACTH Exercise induced amenorrhea > >FT4,ACTH Anxiety induced amenorrhea >FT4,ACTH, urine cortisol level, progesterone challange test History:MSWC Detail Ob/gyn questions, Menopause, Pituitary tumor symptoms ,fatigue, (Others:primary/secondary amenorrhea, fat diet/Diet for anorexia nervosa ,Vigorous exrcise) PE:HEENT(EOM, visual field),Neck(thyroid), CV+P, Full abd,Ext(inspection, DTR) Pediatric #Pediatric:(For smaller child) ON CALL IDIOT, Go A Mile Buy M&M to Family Opening:Hello, Mrs.XYZ, I am doctor Lin, how are you doing? What can I help you? Onset:When did it start? Did he have the same problem before? Number:How often is the pain?Is the problem progressing? Or can use OPDF(Onset/past experience/duration/frequency) Content of stool/Crying:Can you tell me more about his stool? What's the color of the stool? How's the consistency of the stool? Is there any bowel habit change? Is he crying ?any blood Associated Symptoms? Ex: ,URI:Runny Nose, Ear Discharge ,Ear pulling LRI:Coughing, Rapid breathing, wheezing(Chest pain) GI: Vomitting , Diarrhea/Constipation, Difficult swalowling, abdominal distension, (Abdominal pain) CNS: Shaking, (Headache) Skin: rash jaundice Others:Fever, tireness,crying Listless/Lethargic baby: How's his energy level recently? Is your child awake and responsive now? Liquids: Do you notice any change to his urination habits?Is there any color change to the urine?How many wet diapet in a day? Immunization: Are your child's vaccines up to date ? Diet:What's his diet? Is there any change to his diet /appetide? Did you breast-feed/bottle feed your child? When did your child try solid food? Is your child's formula fortified with iron? Did you give your child pediatric multivitamin? Dehydration:How's fluid intake of your child ?(How's his sucking condition now?)Dry mouth or sunken

soft spot over the head?does he has sunken eyes/dry mouth Day care:Has he stayed in day care center ? Infections: Is there anyone around him who has the same problem?How's your immune conditio(HIV mom) ORS counseling Travel:Has he travelled recently with family? Does he use a child seat? Growth: How's his growth?Any weight gain recently?What's his weight/height? Allergy: Is he allergic to anything? Mile stone:when did your child first smile?(2months) ->first sit up(6months) ->start crawling(8months) ->start talking(10months) ->start walking(12 months) ->using short setence(2years) ->learn to dress himself(3 years) ->tie his shoes(5 years) Birth history:Four(full) C Full:Was your pregnancy full term? Checkup: Did you have routine checkups during your pregnancy?(How often?Was an ultrasound preformed? ) Complications: Did you have any complications during your pregnancy/during your delivery/after delivery? Does your child have any medical problem after birth? Cigarette:Did you smoke, drink, or use drugs during your pregnancy? C-section:Was it a vaginal delivery or a C-section? is that a normal delivery? Medical: Did your child have any medical problem after birth? When did he visit physician last time? Has he been admitted to hospital before? Did she has any surgery before? Medicine: Is he taking any medinine recently? Family: Did anyone in your family has the same problem? Ending:Mrs. XYZ, based in the information you were given, your son right now may be experiencing stomach irritation/Loose bowel which need medical attention. We have to determine the cause of it. I would like to do a personal exam on him and perform some basic lab before I can make a definete diagnosis. Will it be convinient to bring him to the hospital? If no->Is there any reason why it's not possible for you? If transportantion problem->Call a cab or 911. If financial problem->social worker Ms.XYZ, I want you to know this is for the best interest of your child, I will see you and your child once you get to the hospital. Take care. #Pediatric(For biggeer child) Ask like adult LQQ OPERA PAM HUGS FAST+(No Ob/gyn, sexual, exercise, Soda) +Beg Mi Birth history(Ask full/complications) Energy Growth(weight/height/language) Milestone Immunization

#CHILD FEVER Physical exam, CBC/electrolytes/blood culture Sepsis Neonatal Sepsis UA/Urine culture,CXR, LP HEENT Acute Otitis Media >pneumonic otoscopy Respiratory Pneumonia >CXR URI >throat swab for culture Rash Viral exanthema(Rubella, Roseola, Scarlet Fever, Varicella,Fifth disease) >throat culture, parvovirus B19/varicella antibodies, skin lesion scrapings Meningitis >LP, platlet, PT/PTT/D-dimer/FDP/fibrinogen(for DIC) GI Gastroenteritis >stool exam and culture, AXR Food Poisoning >AXR Volvulus > AXR Urinary UTI >UA/Urine culture #Child has diarrhea: CBC/electrolytes/Rotavirus enzyme immunoassay/Blood cultures,Stool leukocytes+culture+ova+parasite+pH, UA, AXR Rotavirus Bacterial diarrhea Malabsorption UTI >UA+culture Intussusception Bacteremia Histroy:Number of wet diaper, (Others: Relationship to oral intake) #Child diagnose with DM Glucose/electrolytes/HbA1C/insulin/C-peptide level, islet cell antibody, UA+microalbumin/24 hours free cortisol Type 1 DM Type 2 DM secondary DM Dysmetabolic syndrome X Prader willi syndrome History:DM constitutional symptoms, insulin questions Tingling or numbness in limbs, Infections of skin/gums, Itchy skin, LOC (Other:Blood sugar: Has low blood sugar? Effect on parents/child, weight and height, Any specic diet, Exercise and playful activities, mood,Sleeping problems) Counsel: 1. combination of insulin, balanced diet and regular exercise 2. Attend diabetes class with your daughter 3. Recognize sign of low blood sugar and carry glucose tablet/fluit juice as emergeency kit

#Jaundice in child Tota/indirect bilirubin/Blood typing/Direct Coombs test, CRP/CBC Titers for CMV, toxoplasmosis, and rubella Physiologic jaundice ABO or Rh incompatibility Neonatal sepsis Breast-feeding jaundice Cephalohematoma Polycythemia Familial neonatal hyperbilirubinemia HistoryBowel: Color of stool/Blood in stool, Frequency of bowel movements, , Urinary frequency, urine color (Others:Parts of body involved,Mother/father/baby blood type ,Ill contacts, sister/brother ill Other pregnancies/miscarriages) Counsel 1.Naturall jaundice most obvious on day 4-5, and disappear oveer 1-2 weeks 2.Breast Feeding and some birth defect can also be the cause 3. Pigment level too high can cause damage of brain #Child with stridor CBC/DC/ABG ,XRneck/chest, AP/ lateral, Direct laryngoscopy/ Bronchoscopy Infection Croup Laryngitis Epiglottitis Retropharyngeal abscess/Peritonsillar abscess Non infection Angioedema Foreign body aspiration Laryngeal papilloma History:Drooling, Sound of cough(barking) /voice(Hoarseness) /stidor, Snoring, Crying (mufed or weak), Blueness of skin or ngers (Others: Best heard on inhalation/ exhaling air, activity that procede the event, History of allergies in the family, stress) Foreign body aspiration Counsel 1.Dont put finger into his mouth 2.Heimlich maneuver,standing at his back, thrusting tummy with sudden pressure #BEHAVIORAL PROBLEMS Physical exam/Mental status exam/Urine toxicology ADHD Adjustment disorder Age-appropriate Behavior Conduct Disorder Manic episode Oppositional Defiant Disorder Substance abuse

History:ADHD symptoms, severity, triggers; physical violence ,use of weapons; substance use, developmental history, changes in environment(child abuse), school performance, relationship with classmates/parents, mood/sleep #Picky eater: CBC/TSH/lead level/electrolytes Selective Eating Disorder Lead poisoning adjustment disorder Hypothyroidism ADHD History:diet? any specific food? schedule of the meal? High caroli drink between the meal?Any sneaks between meal?stress on family/him? Activity doing before/during meal? Any dessert served during meal? Reward/ punishment?Appetite, weight change, abdominal symptoms, old house for lead poisoning, conflict in the family, relationship with people/parents Counselling: 1.The key to coping with a child's picky eating is patience 2.Avoid giving your child food between the scheduled times. 3..Set a Meal Schedule 4.Dont punish, bribe or reward their children's eating behaviors 5.Be patient with new foods 6.Don't Always Offer Dessert 7.No juice, milk and snacks for at least one hour before meals 8.Mealtime conversation should be pleasant, Mealtime is not a time for watching television or arguing. #Bed wetting Genital exam, UA+culture, First-morning urine specic gravity, U/S renal Urinary primary nocturnal enuresis Secondary enuresis Functional bladder disorder Urinary tract infection Others Constipation Sleep apnea History:Primary or secondary ?Punished /rewarded him? Stress/sleep/snore/support Urinary symptoms(Infection /irritative and urine color change) ,volume of urine/fluid intake/late night drinking, Frequency of bed wetting/go to toilet, Nighttime awakening, daytime bed wetting, new environment,behavior affected child/parent?Neurological development abnormality? Counsel:1.No punishing ,praising and rewarding him if he stays dry while sleeping. 2.monitor your child's drinking habits before going to bed and encourage the child to go to bathroom before going to bed. 3.We also need to do some tests to rule out other conditions.

Phychiatry #anxiety+ SOB CBC/TSH, EKG , TSH, Urinalysis, Urine Tox screen Phychiatric Hypochondriasis Panic attack Generalized anxiety disorder Adjustment disorder PTSD Substance abuse Malingering Medical Hyperthyroidism arrhythmias, pheochromocytoma Anemia History: CV symptoms,Pulmonary symptoms, hyperthyroid symptoms, feelings of terror ,sweating, headache for pheochromocytoma (Others: family support, restriuction of activity) PE:HEENT(eyes/mouth), Neck(thyroid/LN), CV+P, Ext(Tremor) #DEPRESSED MOOD Physical exam, Mental status exam, CBC/TSH, urine toxicology Phycological Major Depressive Disorder Bipolar Disorder Cyclothymic Disorder Dysthymic Disorder Schizoaffective Disorder Emotional trauma Normal Bereavement Adjustment Disorder Substance/endocrine Substance Induced Mood Disorder Hypothyroidism Ask MS .WC+SIG E CAPS in Depression case Sleep: how's your sleep recently? Interests:What's your hobby? Do you still find them interesting? guilty: Are you feeling guilty about things? Energy:How's your energy level recently? Have you been experiened good mood followed by depressed mood? Concentration: Do you have trouble concentrating? Appetite/Attention(Memory):How's your appetite?How's your memory? Performing job/Pistol:Do you have any problem performing jobs?Do you have any gun in your house?) Suicide/Support/Schizophenia:Have you thought of ending your life? Is there anyone you can talk to when you are feeling down?Do you see or hear things that other people dont? (Life/libido:Do you feel life worth living?How's your sexual desire level?)

If no time, ask GCS (Guilt, Concentration,Sleep/Suicide) PE:HEENT(eye/mouth)Neck (thyroid), Neuro(only MMSE, reflex), CV+P Counsel:1.make an appointment with our counselor, may refer to phychiatrist 2. spend more time with support system(friend/family), and give telephone number of support group 3. write you a prescription for an antidepressant. 4. seek medical attention when feel like hurting yourself #INSOMNIA CBC/TSH/electrolytes, polysomnography Without fatigue Stressinduced Caffeine-induced >urine toxicology hyperthyroidism With Fatigue Sleep Apnea Primary Hypersomnia Major depressive disorder >MSE Circadian Rhythm Sleep Disorder Mnemonic: Daytime Dancing Before Sleep Bothering Sleep Pattern Definition: Do you have any problem falling asleep? Wake up many times in the night ? wake up very early in the morning? Daytime:Do you feel sleepy during the daytime? Do you take daytime naps?Snoring? Before Sleep:What activity do you usually do before you go to sleep? Do you drink coffee/smoke/alcohol before you go to sleep? Bothering:Anything bothering you while you are sleeping? Is there any nightmare/coughing/SOB / urge to urinate/Pain keep you awake? Symptoms/stress:Urinary/bowel movement, Hypothyroid/hyperthyroid, mood, stress? weight/appetite, morning headache Pattern/Pills: How many hours do you sleep? What time do you fall asleep? How long does it take to fall asleep?Has there been any change to your sleeping pattern? Do you take any pills to help you sleep? PE:HEENT(mouth)Neck(Inspection/palpation/auscultation of thyroid,LN),CV+P,,Abd, Ext(tremor,edema, reflex) Counsel: 1.Keep regular bedtime and awake time 2.no use of alcohol/caffeine/nicotine 3. use the bedroom only for sleep,no worries on the bed, 4. no daytime naps 5. exposure to sunlight in late afternoon, #PSYCHOSIS Mental status exam, CBC/TSH/Electrolytes, urine toxicology Without depressive mood Schizophrenia (>6months) Brief Psychotic Disorder (<1 month)

Schizotypal Personality Disorder Schizophreniform Disorder (1-6month) With depressed mood Depression with Psychotic features Schizoaffective Disorder Medical problem Psychotic Disorder due to Medical condition Substance induced Psychosis >LFT,BUN/Cre Hallucinations questions: Did you see/ hear things that other dont? Did you feel/taste/smell anything strange recently? Did you see things when eyes are closed? Schizophrenia questions: (Control beliefs harm motivation) Do you feel like being controlled? Do you have any beliefs that others may think strange? Do you feel that others want to harm you?have you been thinking about harming yourself or others? does the voice call you to harm others? Do you feel you lose motivation and dont want to contact with people? Life: Is the problem affecting life/ job? Have you been thinking about harming yourself or others? Symptoms: CNS: Headache/head trauma? Do you have any vision/ hearing/speech problem? Sleep/mood:Any problem related to sleep? (Others: stress/traumatic event, mental illness in past history/family history ) PE:Full Neruo( MMSE first),HEENT(Inspected pupils reactivity),CV+P, abd Counsel:peer support group, psychiatry counselling, interview close friend and relative Abuse/Assult #Abuse: Mnemonic: SAFEGARD I dont know if this is a problem for you, but I have seen so many people are dealing with abusive relationship, I'm going to ask this question routinely, are you in a relationship which you are physically hurt, threatened, or feel afriad? Stress&safey:Do you have any kind of Stress in your relationship?Do you feel safe at home? Afriad/abuse of child:Are you afraid? Has your partner ever physically abused you or your children? Family&Friends your family or friends aware of this? Can you tell them? Can they can give you support? Emergency:Do you have an emergency plan? a place to go? Would you like to talk to a social worker to develop an emergency plan? Gun :Is there any gun at home? Have you been thinking about harm yourself or suicide? Alcohol:Is there any alcohol or drugs involved? Relationship with spouse. Depression How's your mood?

Domestic violence counsel: 1.I understand your situation, I can give you the contact number of social service who can help you 2.I will do everything I can to maintain your safty 3.The violence never ends on it own, it will get worst over time, the only way to end the abusive relationship is to get away with the abuser. 4. I will reaassure everything we discuss today will keep confidential 5.We have wonderful domestic violence conseller who can solve your problem if you doesnt come out with an emergency plan or have no saft place to stay. 6. have to let child protective service involved because your child cant grow in a violent enviornment Elderly abuse counsel: 1.understand that you want to keep family affair under cover, but usually the family problem could be worse and worse if we don't stop at at right time,its my duty to let the adult protective services know, I will give also give you their phone number to you too. 2.moving to an apartment complex for seniors? #Rape:Pelvic exam, HIV antibody/VDRL/HBV antigen, Wet mount, KOH prep/cervical culture/Evidence collection, Urine hCG, XRskeletal survey/CXR Domestic Violence Osteogenesis imperfecta Substance abuse Consensual Violent Sexual Behavior Incidence: Incident location? Did you recognize the assailants? Did you report the incident? Assult: Description of the assault? objects assault or sexual assault? Sexual:Did they use condoms?Did ejaculation occur?Any foreign objects used?What type of intercourse (oral, vaginal, anal)? Symptoms:Bleeding(Vaginal bleeding, Bleeding or bruises, Blood in stool/urine), CNS symptoms after trauma(see below), System review symptoms HEENT(eye, mouth), CV+P, full abd, Ext(the bruises) Counsel: 1.collect some specimens and swabs from your body and genital area, 2.look for STDs,pregnancy test,emergency contraception. antibiotics to protect you from infections. 3.social worker come talk to you and provide you with phone numbers for support groups Constitutial Symptoms #NIGHT SWEATS CBC/ESR/blood cultures/TSH, CXR, PPD Infection Tuberculosis Acute HIV Infection >HIV antibody Endocarditis Endocrine Hyperthyroidism pheochromocytoma hypoglycemia

Neoplastic Lymphoma >CT chest/abdomen Leukemia >CT chest/abdomen solid tumor >CT chest/abdomen Rheumatology RA, lupus, Temporal artheritis Others: Drug induced History:constitutional/hyperthyroidism/TB/oncology symptoms/menopause, recent URI, rash (Others:ill/TB contact, HIV risk,LMP for menopause) PE:HEENT(nose, mouth), Neck(LN, thyroid), CV+P, abd(liver, spleen), Ext(joint pain, tremor, Janeway lesion, osler node) #FATIGUE & SLEEPINESS Phycological Chronic Fatigue syndrome Depression PTSD Cancer colon cancer >colonscopy, rectum exam, FOBT, barium enema Metabolic Hypercalcemia Diabetes Mellitus Hypothyroidism Sleep Obstructive Sleep Apnea >Nocturnal pulse oximetry, polysomnography Sleep Deprivation Narcolepsy Infection HIV Hema Anemia History:MC.WC ,associated event, progression during the day(about visual change for MG), affecting job/performance,(Others:history of bleeding/anemia, diet, exercise too much) PE:HEENT(conjunctiva,mouth),Neck:(thyroid, LN),CV+P,Full abd,Ext(DTR/edema) #WEIGHT GAIN CBC/glucose/TSH/lipid, urine cortisol/hCG, dexamethasone suppression test Endrcrine Hypothyroidism Cushings disease Diabetes mellitus familiar obesity ObGyn Polycystic Ovary Syndrome Pregnancy

Phychiatric Atypical depression Substance intake Smoking cessation Drug Side effect HistoryMS.WC, increase body hair/ voice change,detail MC/ pregnant history(for PCOD), (Other: vascular risk factor,steroid use, medication change,smoking cessation) PE:HEENT(conjunctiva,mouth),Neck:(thyroid, LN),CV+P,Full abd,Ext(DTR/edema) #WEIGHT LOSS TSH/CBC/electrolytes/HIV antibody Endocrine Hyperthyroidism >FT4 GI Anorexia nervosa >FT4/ACTH/FSH/LH Dieting / Drugs >urine toxicology Malabsorption Malignant condition Cancer >depends on what kind HIV Infection History:MSWC constitutional symptoms, oncology, anorexia nervosa questions, diarrhea (Others:HIV risk factors) PE:Neck(thyroid, LN), CV+P, full abd, Ext(inspection)

Others #DM drugs refills:: History:DM complication symptoms, weight/appetite change,night sweats (Others: Medication questions ,history of hypercholesterolemia/heart/stroke/HTN, last visual check) PE:HEENT (fundus),Neck(Carotid bruit) CV(+PMI)+P, Ext(pulse), Neuro(Muscle power, sensation, DTR) , #Hypertension follow up blood pressure of both arm, CBC/sugar/electrolytes/lipid profile, UA History:HTN complication symptoms, legs or buttock pain,weight/appetite change (Others:history of hypercholesterolemia/ heart problems/ stroke/DM) PE:HEENT (fundus),Neck(Carotid bruit) CV(+PMI)+P, Ext(pulse), Neuro(Muscle power, sensation, DTR) #ERECTYLE DYSFUNCTION genital exam, rectal exam, FSH/LH/testosterone/Glucose/prolactin/TSH, MRI brain, U/S doppler penis/dynamic carvenosography

Drug related ED ED caused by Vascular disease Psychogenic ED hypogonardism peynonies disease History: mpotence severity,sexual desire, early morning/Noctural erection, ejecculation ability CNS:urine/stool incotinence, legs weakness/numbness, headache(pituitary tumor) (Others: History of vasular risk factor/trauma, mood, stress) PE:Neck(Carotid bruit) CV(+PMI), Ext(pulse), Neuro(Muscle power, sensation, DTR) #Terminal cancer: History:symtoms specific questions, (Others:mood,sleep, Hospice care/living will) PE:HEENT(eye for pale conjunctiva,jaundice ), Neck(LN), CV+P, full abd(liver, spleen) Counsel: 1.Hospice care is a multifuntional group of people who is going to take care of you physically, emotionally and spiritually, they can be provided at your home to make you as comfortable as possible 2.Living will enable you to live the way you wanted when you reach to terminal stage, also you c an give the right to make decision to your loved ones. #MVA with chest pain Blood alcohol level/ ABG, CXR/KUB,Urine toxicology ,CT abdomen, Pneumothorax Hemothorax Rib fracture Splenic rupture History:system review /CNS symptoms after trauma (Otheres:other trauma, Last meal/drink, under inuence alcohol or recreational drugs right now?) PE:HEENT(head inspection,palpation,mouth, eye for anemia), CV+full P, full abd(liver/spleen palpation), Neuro(Mental status, cranial nerves, gross motor), Ext(Inspect/palpation) #Pre-employment medical checkup: History:system review /CV symptoms,CNS(Loss of consciousness/seizures Weakness/numbness), Joint pain or swelling, Change in stool color, (Others: Vaccinations) PE;HEENT(mouth), Neck(carotid pruit,LN),CV+P, full Abd, Ext (inspection) Neuro(CN, motor, DTRs, gait) #HIV drug refill CBC/DC, CD4,viral load, CXR, LFT (Zidovudine Toxicity) D/D depending upon case ( PCP, Candida infection, CMV Retinitis, esophagitis) History:drugs problems, system review, eye problems, oral ulcers and white patches ,

swallowing , skin problems and rash ,genital problems,mood (Others:support ,vaccinations ) #Alcoholism CBC/LFT/rGT History:CAGE+marital, finantial, sexual/family/work PE:HEENT(conjuntiva/sclera, oral), CV+P, Abd, Ext(edema) #Rash History:tenderness/numbness/itching/buring on rash, progression of rash, joint pain, oral ulcer, other SLE symptoms, sick contact