step2 cs notes
TRANSCRIPT
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STEP 2 CS Cases
SOB
I can see that you are in great distress. Is there anything that I can do to make u more
comfortable?
D/D:
Acute causes- CHF, Asthma Chronic causes-CO!
"#$! %ronchiectasis
%ronchitis &%
neuomonitis 'ung ca Foreign body I'!
(orku):
C%C
C*$
eak flo+ measurement
F&sethacholine challenge test
)utum for gm stain and culture
! O # F C A A A
A-is it aggra/ated on +alking,slee)ing or resting?
F 0 1 & & & &
Associated symps: do u ha/e O% at rest? If no, ho+ far can u +alk b2f u get O%?
!o u +ake u) at night because of O%?
!o u use any )illo+s because of O%? If yes, ho+ many )illo+s?
!o u ha/e any cough? If yes-CA%CO
!o u ha/e any +hee3e, runny nose, facial )ain?-4$&I, neumonia
!o u ha/e55&% sym)s?
!o u ha/e any55.."#$! sym)s?
Are u getting your flu shots regularly?!id u tra/el recently?
!o you ha/e any55.CHF sym)s?
anic attacks-are u an6ious of anything?
Closure and advice:
It could be- infection of your chest or e6acerbation of your )re/ious condition or long standing
smoking habit or hy)ersensiti/ity of your air+ays
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CHEST PAI
D/D:
C1- I, Angina, ericarditis, Aortic dissection
$es)- leuritis, #"I- "#$!, 4!, "astritis, !iffuse eoso)hageal s)asm
8- Costochondritis, $ib fracture, uscle strain
(orku):
#C"
C8 %, &ro)onin
C*$
C%C, electrolytes
#chocardiogra)hy
Cardiac catheri3ation
#oso)hageal )h monitoring
4))er endosco)y
C& chest for #
! O # C F C A A A
Associates symps:
C1- do u ha/e any O%?? #6cessi/e s+eating? 0ausea? +elling of your ankle or feet? $ashand 9oint )ains? $F or Co6sackie /irus;, $acing of heart, light headedness, )assed out?
!o you ha/e any "#$! sym)s?
$es)- do u ha/e any cough, +hee3e, runny nose?
!o u ha/e any )ain in your legs +hile +alking?-!1& and #
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PA!PITATIOS
!!: code CHAA&I (orku):
c-caffeine serum "lucose
h-hy)oglycemia,HOC,hy)er/entilation C%C, electrolytesa-anemia &H
)-)anic attacks, )hreochromocytoma %40, creatininea-arrythmias,an6iety #C", Holter monitoring
t-thyroto6icosis
i-induced by drugs
s-stress
atient c2o funny sensation2+eird sensation in the chest or )ounding or racing of the heart
! O # C F A A
F-ho+ long does each e)isode last
$egular or irregular
Ask all C1 and $ sym)toms
Coffee- do u drink coffee? If yes, ho+ many cu)s or times )er day?
Anemia- any bleeding )oints in your body and 'OC )assed out; and feeling tired?
An6iety-are u an6ious about anything? Any stress in life?
Hy)ogly-do u take your meals regularly? !id you e/er ski) meals? Any relation to meals?heo-any headache, e6cessi/e s+eating, +eakness?
HOC-any sudden death in the family?
F 0 1 & & &
&-&hyroid- any e6cessi/e s+eating, shaky m/nts of hands, any skin changes, heat intolerance?
Closure and advice: lease cut do+n on caffeine
tress counselor-can hel) you by teaching rela6ation te=sIf on thyroid hormone-ha/e regular thyroid le/el check u) and get the dosage accordingly
If hy)oglycemic-donot ski) your meals and ha/e a regular diet
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D"SPHA#IA
C-carcinoma eoso)hagus, C1A
A-achalasia cardia
"-"#$! +ith stricture#eoso)hagitisH1,C1, Candida, )ill induced;
-scleroderma or C$#& syndF-foreign body obstruction
"-mystenia gra/is
@-3enkers di/erticulum
-)lummer 1inson synd
(orku): Iron studies&I%C, s. iron, s. ferritin;, &H, )lain c6r, barium s+allo+, C& chest,
endosco)y +ith bio)sy, eoso)hageal manometry, HI1 testing, Anti-centromere antibodies
Associated symps: !o u feel food get struck?
Can u locate +here u feel the food struck?
!o u ha/e difficulty s+allo+ing li=uids or solids of both? If both, then +ith started first?
!o u ha/e any )ain +hile s+allo+ing?!o u ha/e any +ater brash or heart burn?
!id u notice any food )articles on your )illo+ +hen u get u) from your bed?
!id you ha/e any e)isodes of choking?
!o u ha/e any drooling?!o u ha/e any halitosis?
!o your fingers change in color +hen e6)osed to cold or emotions? !id u notice any skin
changes?
Closure and advice-
"ro+th in your food )i)e or infection, foreign body obstruction
&ake soft foods slo+ly in small amounts. If )roblem +ith li=uids then start I1 line, "#$!
counseling
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HOA$SEESS
D/D: $efle6 )haryngitis (orku):
1ocal cord ca Indirect larnygosco)y
'aryngeal ca C%C1ocal nodules or )oly)s &H
1ocal cord or $ecurrent laryngeal ner/e )alsy 4))er "I endosco)yHy)othyroidism
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SO$ETH$OAT
Code: 4 " H I
D/D:Infectous mononucleosis
tre)tococcal )haryngitis4$&I
1iral )haryingitis
%acterial )haryngitis
Acute Hi/ infection
"#$!
(orku):
C%C, )eri)heral smear, onos)ot test
&hroat s+ab for culture sensiti/ity
HI1 ab and /iral load
Anti #%1 abs
1!$' and $$'F&sA&, A'&, bilirubin, A';
Associated symps: !o u ha/e any fatigue, diff s+allo+ing, belly )ain?-I
Any fe/er, runny nose, cough, O%?-4$&I!o u ha/e any facial )ain?-sinusitis
!o y ha/e any ear )ain or discharge?
!id u notice any s+ollen glands2'02dys)hagia? If yes, are glands )ainful?
!o you ha/e any rash, 9oint )ain?- $heumatic fe/er
!o you ha/e any change in color of urine?-"%,"0
!o you ha/e any "#$! sym)s?
Closure and advice:Ad/ice HI1 testing, safe se6ual )racticeA/oid contact s)orts, strenuous e6ercise-&o a/oid the risk of s)lenic ru)ture
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HE%OPT"SIS
D/D:
ulmonary &%ulm edema
%ronchogenic ca%ronchitis
neumonia
ulmonary embolism
'ung abscess
A1 malformation
&or'up:
C%C, C*$, %lood cultures, 4A24C, )iral C&, 'ung bio)sy, %ronchosco)y
! O # F C A A A
C A % C O
%lood-dark colored or fresh blood or blood clots?
Associated symps: do u ha/e any chest )ain or O%?-Heart sym)s
!o you ha/e any +hee3e?-'ung sym)sHo+ is your a))etite? !o you ha/e any e/ening rise of tem)? Any ill contacts? (hen +as your
last !?-&% sym)s
Ha/e u been restricted to any one )osition because of hos)itali3ation or tra/el?-#
Closure and ad/ice:
D
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CO(#H
D/D:
4$&I
&%CO!
Acute %ronchitisbronchiectasis
neumonia
%ronchogenic carcinoma
Foreign body
"#$!
&or'up:
C%C
C*$
)utum for gm stain and culture
!
! O # C F A A A
A-is it +orse during any )art of the day2season2)osture?
!o you bring u) anything in your cough? #g-)helgum. If yes-CA%CO
!o you ha/e any O%? 0!? Ortho)nea? Ankle s+elling? al)itationsracing of heart;,assout?-CO!, CHF
!o you ha/e any runny nose? Facial )ain?
!o you ha/e any dri))ing sensation in your throat?
!o u ha/e any soreness in your throat?
!o u ha/e any +hee3e?
!o you ha/e any +aterbrash? Heartburn? %elly )ain?
!o u ha/e any 55..&% and "#$! sym)s?
A H 4 " F O -AC# inhibitors?
Closure: could be due to hy)ersensiti/ity of your air+ay
Advice:!ont indulge in acti/ities that increase your breathessness
"#$!-ha/e meals < hours before going to bed, no caffeine, no smokinghysiothera)ist for breathing e6ercises
4se tissues +hen u cough
4se face mask +hen you r at +ork
&ake ade=uate rest and nutrition and hydrationIf u are allergic to anything, then a/oid it
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)O%ITTI#
D/Dcode: 1 O I & I 0 " H
1- 1ertigo
O-O%")regnancy;, obstruction-igraine, otion sickness
I-Inflammationancreatitis, )yelone)hritis, cholechysitis&-&reatmentchemothera)y, surgeries )aralytic ileus, adhesions;
"-gastroenteritis
H-hy)ercalcemia
(orku):
4rine HC"
el/ic e6am
42 )el/is
C%C, electrolytes, Ca, "lucose
4rine analysis and culture
! O # C F A A AC A % C O
Associated symps:
!o u ha/e any belly )ain?-"astritis!o u ha/e any back )ain? yelone)hritis, )ancreatitis
!o u feel the room is s)inning around you?-1ertigo
!id you eat food outside?-"#
A H 4 " F O
-chemothera)y?
4-4&I sym)s?
O-menstrual historyG Is there any chance of you being )regnant?
Closure and advice:
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BE!!" PAI
D/D: code "OA'I$
":"%-cholecystitis, choledocolithiasis
O: O%"0-I!, #cto)ic )regnancy, endometriosis, adenomyosis, o/arian cyst or torsion:ancreas-Acute )ancreatitis
A:A))endicitis':'i/er-Amoebiasis, hydadid cyst, he)atic congestion
:tomach-"#$!, 4!
I:Intesines-C!, 4C, !i/erticulitis, mesenteric ischemia
$:$enal stones, $CC
(orku):
$ectal e6am
erum Amylase and li)ase
'F& A'&,A&, bilirubin, A';
#ndosco)y for H.ylori testing
4))er "I series
42 abdomenC& abdomen
42 )el/is, 4rine HC"
! O # C F A A A
' I J $
F 0 1 & & & &
!o u ha/e any occu)ational stress?
A H 4 " F O
-+hen +as your last colonosco)y done?H-any )re/ious a))endicectomy or I! history
4-do u ha/e any burning sensation +hile )assing urine? !id u e/er notice blood in urine or +hat
is the color of your urine?-0e)hrolithiasis
"-ho+ are your bo+el m/mts? Ho+ often do you )ass your stools? !o u ha/e any )ain +hile
)assing stools? !id you notice any blood in your stools? (hat is the color of your stools? Any
alternating bo+el habits? CA%CO
Closure and advice:
7K
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B!EEDI# PE$ $ECT(%
D/Dcode: CHA!
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HE%AT($IA
D/D: code HI&$ (orku):
-stones in bladder or ureter "enitourinary e6am
H-hematologic 4rine analysis and cytologyI-infection"% infections, chistosomiasis; %40, creatinine, A
&-trauma &, A&&&-tumor $CC, %ladder ca; 42 renal bladder
#-e6ercise rhabdomyolysis; C& abdomen and )e/is
$- $enal"0, C8!; I1
! O # C F A A A
C-do u see blood e/erytime u )ass urine? If no, then ho+ often?
Ho+ much? (hen did u notice blood? i.e before2during2after2through out )assing the urine
Associated symps:
!o u ha/e any burning sensation?
!o u ha/e to rush to the bathroom to )ass urine? urgency;
!o u ha/e to get u) in the night? nocturia;Ho+ is your stream? any +eak stream;
!o u ha/e to strain to )ass urine? straining;
!o u ha/e to +ait before )assing urine? hesitancy;
!id you ha/e any urinary in9ury?!o you any dribbling or leaking of urine? incontinence;
!id you notice any )us in urine?
!o you ha/e any )ain in your back? flank )ain;
Ha/e u e/er been diagnosed to ha/e kidney stones? Ha/e u e/er )assed stones in your urine?
!o you ha/e any sore throat? Loint )ains? %ack )ain?
!o you ha/e any bleeding )oints any+here in your body?
Ha/e u e6ercised strenuously?
Closure and advice:
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*ATI#(E +*eelin, lo- or .eelin, tired
D/D: code HO!CA (orku):
H- hy)othyroidism, HI1 C%C, electrolytes, calcium
O- obstructi/e slee) a)nea, occult malignancy &H!-!, de)ression, domestic /iolence HI1 and &! testing
C-caregi/er fatigue, com)assion fatigue,colon ca olysomnogra)hyA-anemia, ad9ustment disorder 0octural )ulse o6imetry
-myasthenia gra/is, malignancy Colonosco)y
-)regnancy, &!
Associated symps:
Hy)othyroidism- do you ha/e any )roblems ad9usting +ith surrounding tem)? !o you ha/e any
sonsti)ation? Any hair fall? Any hoarseness of /oice? Any dryness of skin? Any belly )ain or
discomfortfor consti)ation;?
OA- !id anyone notice u snoring at night? !o you feel refreshed after +aking u) in the
morning? !o u feel tired and slee)y during daytime?
HI1 and malignancy- Ho+ is your a))etite? !o u ha/e any recent +eight changes?
!e)ression- Ho+ is your mood? If good, then ask for IC# MHo+ is your interest no+adays? (hat are your hobbies? !o u en9oy them?
Ho+ is your concentration?
Ho+ are you energy le/els?
If mood is bad, then ask for "- Ho+ is your slee)?
I- interest?
"-guilty?
#- energy?
C- concentration?
A- a))etite?
- )sychomotor changes? any irritability;
-suicidal tendencies? do u feel like hurting yourself?; If yes, then gi/e suicidal counseling
!- do u feel any increase in thirst and hunger? !o you feel any increase in fre=uency or
urination?
!omestic /iolence- are u being )hysically or emotionally hurt or abused by anybody? Are you
feeling safe or are u afraid at home?
Anemia-do u ha/e any racing of heart? Any O%? Any belly )ain? Any bleeding )oints?
Ad9ustment disorder- do u ha/e any stress at +ork or home?
yasthenia gra/is- did u notice any droo)ing of eyelids? Any double /ision? Any increasedfatigue to+ards the end of the day?
&!-do u ha/e any flashbacks or nightmares of any e/ents?
It sound like u are losing ho)e. Ha/e u e/er thought of hurting yourself or try to do so?
Closure and ad/ice:
7>
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HEA$I# !OSS
!2! code: A0F'OI&
-meniers disease
A-acoustic neuroma0-noise indused
F-foreign body'-labrynthitis
O-otosclerosis, ototo6ic drugs, otitis media
-)resbycusis, )erilym)thatic fistula
I-im)acted +a6
&-trauma
(orku):
audiometry,
tym)anometry
C& head
brain stem auditory e/oked )otentials
C%C, #$, electrolytes, 1!$'
Hello r.6, y nurse told me that u ha/e )roblem +ith your hearing. Am I audible to you? !o u
+ant me to come closer. ay I kno+ in +hich ear u can hear me from this )osition? If both years,
then say Nsorry.%e near to the ear in +hich the can hear and start your introduction: I am !r.$a/i, the
attending )hysician in this medical center and I +ill be taking care of you today555..
Associated sym)toms:
Otitis media and labrynthitis-do u ha/e any ear )ain? If so then ask 'IJ$. !o u ha/e any ear
discharge? ask CA%CO;. !o u ha/e a runny nose, sore throat, cough? !o u ha/e any
imbalance? !o u ha/e any ringing sensation in the ear? !o u ha/e any fullness in your ear? !o
you ha/e any feeling of room s)inning around u?Ha/e u e/er been e6)osed to loud noises?
Acoustic neuroma- do u ha/e any headaches? Any facial )ain or facial +eakness? !o u ha/e any
/ision )roblems?
F%- did u insert any fb either accidentally or intentionally in to your ear?
&rauma- did u e/er ha/e any trauma to your ear?
Is there any h2o recent infection and treatment?
Ototo6ic drugs- as)irin, HC&@, aminoglycosides,
!o u hear +ords 9umbled or distorted?
Can u locate the source of sounds?
!o u ha/e any )roblem understanding s)eech?
!oes it effect your life style?
F 0 1 & & & & - did you ha/e any airtra/el recently or scuba di/ing?
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#6amination: do $innes, (ebers, sinuses, C0s
Closure and ad/ice:#ar )lugs- I can +rite a letter to your em)loyer to shift u to noise free )laces.
It is ob/ious from my e6amination that you ha/e hearing loss, but it could also be due to somere/ersible causes. &reating them may restore your hearing and for that I need to rule out some
re/ersible causes.
ean+hile, +ith your )ermission I +ill make an a))ointment +ith an audiometrist +ho can hel)
u +ith some hearing aids.
CJ: Am I going to be deaf?
7B
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DI00IESS
!2! code: HO%'AA
H-hy)oglycemia
-meniers diseaseO-orthostatic htn
%-%1'-labrynthitis
A-acoustic neuroma
A-arrythmias
-)erilym)hatic fistula trauma;
-stroke
(orku):
-1!$', $$
O-orthostatic /ital signs
%-audiogram, dicks hall)ikes maneu/ure
C%C, electroly, blood sugar
C& head, $I brain
Associated sym)toms:
(hat e6actly do u mean by di33iness?
! O # C F A A A: A-)osition and time
H-Ha/e u ski))ed any meal?
-do u ha/e any )roblem +ith hearing? Any ringing sensation in your ear? Any sensation of
room s)inning around you?
'-do u ha/e any ear )ain? #ar discharge? Any runny nose? ore throat? Cough?
A- do u ha/e any headaches? 1ision )roblems? Facial +eakness?
A-do u ha/e any racing of heart? Chest )ain? O%?
-do u ha/e any +eakness or numbness or tingling any+here?
#6amination:
Closure and ad/ice:
!o not change your )osition suddenly donot get u) suddenly from lying do+n or sitting do+n
)osition;
4se hand railings +hile u +alklease dont dri/e or go unaccom)anied +hen u go out
!o carry an I.d card +ith )hone numbers of your lo/ed onesA/oid high altitudes
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ISO%IA
!2!: code "C$O4!
"-generali3ed an6iety disorder
-meno)ause, medicationsC-circadian rhythm slee) disorders, coffee
-&!, hy)erthyroidism$-restless leg synd
O-obstructi/e slee) a)nea
4-4&I, %H
!-de)ression, diabetes mellitus
(orku):
olysomnogra)hy
#mental state e6amination;
&H
C%C
#C",##"
4rine to6icology
! O # F A A
!-+hen did it start?
I need to ask u fe+ =s about your slee) )attern. Is that ok +ith you?!o u ha/e )roblems falling aslee)?
Falling aslee)-+hen do u usually go to bed? Ho+ much time do u take to fall aslee)? (hat do u
do before u go to bed? !o u e6ercise? !o u take e6cessi/e coffee or alcohol before going to bed?
!o u +atch t/? moke?
!o u ha/e )roblems staying aslee)?
taying aslee)-Ho+ many hours do u slee)? Ho+ many times do u +ake u) in the middle of the
night? (hat do u think is causing it?
!o you ha/e )roblems like unusual +aking u) early in the morning?
4&I2%H2diabetes mellitus-do u +ake u) to urinate in the middle of the night?
An6iety- are u an6ious about anything?
"#$!-555.ask "#$! sym)s;
eno)ause- do u ha/e any hot flashes? #6cessi/e s+eating?
Circadian rhythm-do u ha/e any recent changes in +ork shifts?
&!-do u get any nightmares or flashbacks of those e/ents?
$estless leg syndrome- does any one notice fre=uent m/mts of your legs during your slee)?
OA-do u feel slee)y during daytimes? !o u feel refreshed after u +ake u) in the morning? !o u
feel slee)y during the day? !id anyone notice u snoring +hen aslee)?
!e)ression-ho+ is your mood?
If good, then ask interest,conc, energy le/elsIC#;
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If bad, then ask I"#CA
#6amination:
In C0, do # i.e OCL;
O-orientationtime,)lace,)erson;do u kno+ +hat time of the day it is? !o u kno+ +here are ukno+? !o u kno+ +ho I am?
-memoryremote,recent,immediate; +hat is your date of birth? (hat did u ha/e for lunch
yesterday? Ill tell you the name of > things, )lease re)eat them for me
C-concentration-Can u s)ell the +ord book back+ords for me?
L-9udgement-+hat +ill u do if u see a cloth catching fire?
If you dont ha/e time for #, ask the )t +hats his name? +here are you? +hos the
)resident of 4? (hat day is today?
Closure and ad/ice:
lease maintain a slee) diaryFollo+ regular bedtime and +akeu) times
!ont e6ercise in early e/enings
!onot take caffeine or alcohol and donot smoke before going to bed
lease a/oid +atching t/ on bedA/oid daytime na)s
7E
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HEADACHE
!2!: code CA$&
C-cluster headache, cocaine
A-anesthetic +ithdra+al-sinusitis, subdural hematoma, AH
$-refraction headache-migraine,meningitis
&-tension headache, tumor, trauma, tem)oral arteritis
-)seudotumor cerebri, )rolactinoma, )hreomochromocytoma, )remenstrual synd
(orku):
C%C, #$, electrolytes
C& or $I brain
C& of 0
'
Cluster-do u ha/e )ain around your eye? Any +atering of eyes? Any runny nose?
igraine- do u ha/e any +arning signsnausea,/omiting; b2f the onset of headache? !o u ha/eany discomfort +ith bright light?
eningitis-do u ha/e any neck stiffness? !o u ha/e any ear )ain? #ar discharge? !id u e/er
thro+ a fit?
$efraction and tumor-do u ha/e any /ision changes? !o u ha/e any stress at +ork?
&em)oral arteritis- do u ha/e any 9a+ )ain +hile che+ing?
&rauma- did u ha/e any trauma to your head?
inusitis-!o u ha/e any runny nose? facial )ain?
seudotumor cerebri- do u ha/e any +eakness in your arms or legs? Any tingling or numbness or
+eakness in your arms or legs? !o u ha/e any difficulty in s+allo+ing? Any slurred s)eech? Any
changes in /ision? Any urinary or stool incontinence?
F 0 1 & & & trauma and tumor; A H 4 " F O
-oc )ills, /itA to6icity, tetracycline to6icity
O-occu)ational stress
#6amination: head, C0s, $4C;
Closure and Ad/ice:
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!OSS O* COSCIO(SESS +!OC
t c2o faint e)isode, )ass out or blackout;
!2!: code HO&A1!
H-hy)oglycemia, heat e6haustion, hy)o/olemia, HOCO-orthostatic hy)otension
&-tumor, traumaA-arrythmias, anemia, aortic stenosis
-stroke, &IA, AH,sei3ures, substance inducedcocaine;
1-/aso/agal synco)e, /ertigo
!-drug induced
(orku):
%lood glucose
erum electrolytes, C%C
Orthostatic /itals
C& or $I brain
#8", #CHO, Holter monitoring
##"4rine to6icology
! O #- #-do u relate this )roblem to any e/ent?;
Associated sym)s:
Is this the first e)isode2If no, ho+ many )re/ious e)isodes?
For ho+ long did u lose your consciousness?
!id u lose your consciousness b2f or a2f your fall?
ei3ures-did u smell, see or hear anything unusual or any +arning signs b2f the e/ent? !id
anybody notice shaking or 9erky m/nts of your body? Any tongue biting? Any frothing? !id u
)ass any urine unkno+ingly?
C1-did u ha/e any racing of heart? Any chest )ain?
troke or &IA-did u ha/e any light headedness? Any +eakness or tingling or numbness in your
body?
Hy)oglycemia-did u ha/e any e6cessi/e s+eating? !id you ski) any meal b2f this e/ent?
Heat e6haustion-did u notice any dry mouth b2f the loc?
1ertigo-did you any s)inning sensation or ear )ain? !o you ha/e any )roblem balancing +hile
you +alk?
&rauma-did u ha/e any trauma to your head?
HOC-ha/e you e6ercised strenuously b2f u lost your consciousness?
Hy)o/olemia- did u ha/e any loose stools recently?
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After the e/ent;- did you ha/e any confusion? Any numbness? Any tingling? Any
headache2nausea hy)oglycemia; after the e/ent?
In family history, ask for any sudden deaths
#6amination:
If hy)ertension )resent, do C1If sei3ure acti/ity, do C0 and H##0&
Closure and ad/ice:
lease dont dri/e or go unaccom)anied +hen u go out
!o carry an I.d card +ith )hone numbers of your lo/ed ones
A/oid strenuous acti/ities, e6ercise
A/oid illicit drugs
555until I get your results
CJ:
y +ife asked me to dri/e car, can I?
!id I )ass out due to cocaine?Can I go )lay a match?
Is this the same attack as that of my brother? HOC;
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CO*(SIO O$ *O$#ET*(!!ESS
!2!: code 1A0IH#!
1-/ascular dementia, /it%7< deff
A-al3heimers , AI!0-0H, neurosy)hilis
I-intracranial tumors, infection-IA!H, chronic subdural hematoma
H-hy)othyroidism, hy)oglycemia
#-ence)halitis, electrolyte imbalance
!-de)ression, drugs, diabetes mellitus
(orku):
#
C%C, #$, electrolytes
C& or $I brain
erum %7< le/els
!o))ler 42 carotid
$%,%40,creatine' +ith o)ening )ressure
If family members tell you about it, then ask since ho+ long he2she has been concerned about
this.
! O #
!id u or anybody notice it?
Is it affecting your daily acti/ities?-code !#A&HHAF&
!o you ha/e trouble +ith dressing? #ating? Accounts management? &oiletingusing restroom;?
anaging sho))ing? House kee)ing? Accounting? "oing around or finding home? Cooking?
&ra/el or dri/ing?
Ho+ is your mood? Ask for IC# and I"#CA
C0s-do u ha/e any )roblem +ith s)eaking? +allo+ing? 1ision?
otor-do u ha/e any +eakness in your body?
ensory2/it%7
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(ith your )ermission, I need to talk to your family members to better understand your )roblem
#6amination: #, C0, $motor,sensory,refle6es,)ulses;
Closure and ad/ice:
ou ha/e some )roblem +ith your concentration and memory. It might be due to a )roblem inyour brain or +ith the /essels su))lying your brain or but there are also many other )ossibilities.
o I need to run do+n a fe+ blood tests and imaging studies of your brain
8ee) things organi3ed in your room
aintain a diary listing your acti/ities
!onot dri/e alone
Al+ays be accom)anied by others +hen u go out
lease carry an i.d +ith contact numbers of your lo/ed ones
CJ: is it because I am getting old? (ell, I can understand555.."etting old doesnot mean you
ha/e to ha/e forgetfulness. It could be one reason but there are also se/eral other causes +hich
need to be ruled out and some of them can be effecti/ely treated. In order to be sure I need to run
do+n a fe+ tests55555..
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&EA1ESS I A$% O$ !E#
!!: (orku):
&IA C& head, $I brain
Com)licated migraine !o))ler 42 carotidIntracranial neo)lasm $%, H%A7C le/els
Chronic subdural hematoma erum %7< le/elsHy)oglycemia 0er/e conduction studies
!iabetic )eri)heral neuro)athy C%C, #$, electrolytes
Alcoholic-%7< deficiency
"%
$adiculo)athy
C2O +eakness in arm or leg
! O # C F A A
- )ro6imal to distal
!istribution: +hich )arts of body are in/ol/ed?
ensation: any tingling or numbness? Any )ain? Any headache? Any neck )ain? Any back )ain?If headache )ositi/e then rule out migraine
ei3ures: did you e/er thro+ a fit?
C0-any difficulty in s+allo+ing? In s)eech? In breathing? In /ision?
A0-did you e/er )ass urine or stools unkno+ingly?
Hy)oglycemia-did you e/er ski) your meals?
F 0 1 & & &
&-traumasubdural or e)idural hematoma;
A H 4 " F O -!, H&0, Atherosclerosis
Closure and ad/ice:
A))ointment +ith a )hysiothera)ist
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A(DITO$" HA!!(CIATIOS
!2!: code %A!0
%-%rief )sychotic disorderP7mnth;-due to medical2)sychological2electrolyte imbalance
A-ad9ustment disorder!-drug2substance induced )sychosis
-schi3o)hreniform disorder 7- mnths;G if Mmnths then its schi3o)hrenia-sei3ures
0-narcole)sy
(orku):
4rine to6icology drugs;
C& head and $I brain
C%C,#$, electrolytes
%40, ser creatinine, A'&,A',A&
chi3oaffecti/e disorder schi3o)hrenia Q mood disorder i.e either de)ression or mania
r.*, my nurse told me that you are hearing /oices. lease donot listen to them. &hey are
imaginery not real;. lease concentrate on me r.6. I am here to hel) u and I can do that if youshare your )roblem +ith me. I assure you that e/erything +e discuss +ill be ke)t confidential.
&o interru)t the )t-
#6cuse me r.6, I am sorry to interru)t you. I kno+ these things are bothering u. I need to focus
com)letely on your )resent situation. lease dont concentrate on them, try to concentrate on me.
I understand that you are going through a tough )hase. (e +ill definitely +ork on it together.
!o u hear those /oices e/en +hen you close your ears?
!o you think /oices are controlling you?
! O # F
Auditory-ho+ is it affecting your daily acti/ities?Ho+ many /oices do you hear?
(here do u think they are coming from?
Are u familiar +ith those /oices?
(hat do they say?
1isual-do you see something that others dont? (hat do you see?Ho+ long ha/e u been ha/ing this )roblem?
Olfactory-do you smell anything that others dont?
ensory-do you feel something cra+ling on your body?
uicidal tendency-did you e/er think of hurting yourself2others?
!o you ha/e any )ills2guns in your house?
!elusion-do you ha/e beliefs that others find odd?
ania-do u feel elated?
ood-ho+ is your mood?-IC# and I"#CA
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$elationshi)-ho+ is your relationshi) +ith the family? Are they hel)ful?
!o you ha/e anyone to share your feelings +ith?
Any +eakness2numbness2tingling2incontinence2slurring of s)eech2headache2sei3ures
#6amination:#
C0
0eck-carotid auscultation
CJ:Am I going mad?
r.6, I can understand your a))rehension. Hearing /oices doesnt mean that you are going mad. I
ha/e seen many cases of this kind, +ho are doing +ell no+. %ut to be sure of the diagnosis, I
need to run do+n some tests. lease dont +orry. (hate/er may be the !6, I am here to hel) you
out and gi/e u the best $6 o)tions a/ailable at our hos)ital.
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OIT PAI:
! O # C F A A A ' I J $
Associated sym)s:!id you notice any redness or +armth or s+elling or stiffness?-inflammatory signs;
!o you hear sounds +hile mo/ing your 9oint?!o u ha/e any decreased mo/ent at the 9oint?
!id you do any /igorous e6ercise?
!id you lift any hea/y +eight?for back )ain;
Is it affecting your daily acti/ities?
Are there any similar sym)s in other 9oints?
otor:
!o you ha/e any +eakness any+here in your body?
ensory:
!o you ha/e numbness, tingling? Or )ain else+here in your body?
Autonomic:
!id you e/er )ass urine or stools +ithout your kno+ledge?
ulti)le myeloma-do you ha/e light headedness? Consti)ation? $acing of heart?headache? belly)ain?ask only if back )ain;
F 0 1 & & & &
F-any fe/er?se)tic arthritis;
&-did you ha/e any trauma to your 9oint?
&-tumor-)rostate,lung,breast,multi)le myeloma,lym)homa
C I & $ 4 H &C- runny nose, cough, chest )ain?-/iral infection;
I-infection?-4&I;
&-tick bite?
$-any rash on your body?
4-any ulcers on your body?
-any stiffness of your 9oints?
H any hair loss?
-any )hotosensiti/ity?
&-tem)erature: any changescolor; of fingers on e6)osure to cold?
A H 4 " F O - steroids, H$&,/it!?
4-4&I?
-any disturbed slee) in lying do+n )osition?
O-meno)ause, I4! insertion
-erections2e9aculations )roblems?
#6amination:
tart +ith the normal 9oint
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Ins)ection-look for any redness, s+elling or abnormalities?
al)ation-feel for any +armth,tenderness and for range of mo/ementssay to do as much as
)ossible but dont e6ert your self. If you get any )ain, )lease sto) immediately;
For s)ine-untie
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EC1 PAI:
!2!:
aras)inal muscle strain (orku):
Cer/ical s)ondylosis *ray neck-A and lateral /ie+Cer/ical disc )rola)se or herniation 0er/e conduction studies
$adiculo)athy erum ca )hos)hate and A'$A C%C, #$, serum electrolytes
&raumatic fracture of cer/ical s)ine erum A0A and $F
!egenerati/e disease-Osteoarthritis of cer/ical s)ine
For neck )ain, shoulder )ain, elbo+ )ain-dont gi/e shake hand
For neck )ain-first knot only
Closure and advice:
CA!* PAI +D)T
!!:!1&
Cellulites2myositis
$u)tured bakers cyst
Hamatoma
$u)ture of medial head of gastronemius
)asm due to in9ury or s)rain
Claudication
(orku):
!o))le 42
C& chest, 12J scan
!-dimers
Hy)ercoaguability testing
C%C and !C, #$C8 and myoglobin le/els
C& /enogra)hy
$I legmuscle2tendon ru)ture;
%lood for C2
! O # C F A A' I J $
Associated sym)s:
!id you notice any redness in your legs? rubor;
!o you ha/e the sensation of +armth in your legs? calor;
!o you ha/e any s+elling in your legs?tumor;
'oss of function-Are you able to more your knee 9oint?dolor;
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1aricose /eins-!id you notice any enlarged or dilated /essels on your legs? Any ulcers on legs?
#-!o you ha/e any O%? Any chest )ain? Any cough?
F 0 1 & & & &F-!1&, cellulitis and myositis;
&-traumaany immobili3ation?;,&-tra/el, &-tumorhy)ercoaguability state;-)reci)itating factorsfor !1&
A H 4 " F O
-)re/ious h2o arthritis $A;
-oc)s )reci)itate clotting
H-ortho)edic surgeryimmobili3ation;
F-cholestrolemia, clotting disorders
O-)regnancies, immobili3ation
- i/ drug use
-smokingincreases clotting;, sedentary occu)ation if elderly ;
#6amination:Ins)ection-look for any redness, s+elling or abnormalities?
al)ation-feel for any +armth,tenderness and for range of mo/ements at knee say to do as much
as )ossible but dont e6ert your self. If you get any )ain, )lease sto) immediately;
#licit ratts signs=ee3ing of )osterior calf causes )ain; andHomans sign)assi/e dorsifle6ion of foot causes )ain in calf;
C1 and $ auscultation for #
$- -lo+er limb )ulses
Closure and ad/ice:our condition could be due to a clot in the blood /essel or any infection.
If your results slo+ cots, +e +ill start blod thinners +hich )re/ent further com)lications such as
clot tra/eling to your legs
A/oid immobili3ation for long )eriod of time&ry to mo/e in )lace and )erha)s take a short +alk
If on OCs, )lease sto) using them as this may +orsen the condition.
tudies ha/e sho+n that obesity increases your risk of ha/ing a clot. o, I suggest that you
e6ercise regularly and manage your diet
>K
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DIABETES %E!!IT(S *O!!O& (P
(ell r.6, I am glad that you are here. I a))reciate that you are taking good care of your health.
Ho+ can I hel) you?
atient here for a refill:
I am glad to hel) you. %efore I refill your medication, I need to ask you some =s and do a small)hysical e6amination.
(hen +as it first diagnosed?
ay I kno+ +hat medications you are on?
Are you com)liant +ith your medication?
(hen +as your last doctor /isit? ay I kno+ the result?
!o you check your glucose le/els regularly at home? ay I kno+ the readings?
$etino)athy-!o you get your eye check u)s done regularly? (hen +as the last check u) done?
!o you ha/e any blurring of /ision? !o you ha/e any headaches?
0euro)athy-!o you ha/e any numbness, +eakness or tingling sensation?!o you ha/e )roblems controlling your urine or stool?
!o you ha/e any ulcers or re)eated in9uries to your legs?
Atherosclerosis-!o you ha/e any chest )ain? Any e6cessi/e s+eating? And lightheadedness? Anybelly )ain?
4rination-!o you +akeu) at night? If yes, ho+ many times? Is it disturbing your slee)?
!o you ha/e any burning micturition?
e6ual dysfunction-!o you ha/e any )roblems +ith your se6ual life?
!o you ha/e any early morning erections?
A H 4 " F O
#6amination:
Fundosco)y
0eck, C1, ulmonory
Abdomen#6tremities and 0eurological
(orku):
H%A7C le/els%40, Creatinine
C%C, s.electrolytes
Closure and ad/ice:
$egular eye checku)s
&ake small fre=uent meals and )lease donot ski) meals
4se soft heel )ad shoes
!ont in9ure yourself. If in9ured take )ro)er care as early as )ossible
&ake a diet lo+ in salt, carbs and fat and high in fiber
#6ercise regularly
>7
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*E%A!E CASES
)A#IA! B!EEDI#
!2!: A1%'##!
A- adenomyosis, abortion1-/aginal in9ury
-I!, CO!, )erimeno)ause
%-bleeding diasthesis
'-leiomyomas-hea/y )ainful menstruation, dys)erunia,
#-ecto)ic )regnancy#-endometriosis,endometrial ca
!-!4%, hy)othyroidism
(orku):
el/ic, genital and rectal e6am
4rine HC", 4 )el/is
Cer/ical cultures, endometrial bio)syA smear
&2A&&
'H2FH, )rolcatin,&H
Juantitati/e serum HC"
! O # F A A
F-is it continous flo+ or is it s)otting?
Is this the time +hen you usually get your )eriod?
Associated sym)s:
!o you ha/e any )ain associated +ith bleeding? If yes, 'IJ$. Is it bright red or does it ha/e
clots? !oes it contain any tissue like substance?
1-did you ha/e any trauma or accident?
%-do you ha/e any belly )ain? !o u ha/e any racing of heart? Ankle s+elling? ass outs? !o you
ha/e any bleeding )oints in your body?
A-+hen +as you '? If 'MB +ks, are there any chances of you being )regnant? Are you
cycles regular? Ho+ often do you get them? Ho+ many days do you bleed? Ho+ many )ads do u
change on a healthy day? !o u notice any intermenstrual s)otting? Any )ain during
menstruation? (hen +as your A smear done? If no then gi/e ad/ice. If yes, can I ha/e the
result?
-I!;do you ha/e any /aginal discharge? If yes CA%CO!o you ha/e any /aginal ulcers? Any dryness? Any itching?
erimeno)ause-!o you ha/e any hot flushes?if flushes yes, then did u try any medication for it?
#ndometriosis-!o you ha/e any )ain during menstruation? !uring intercourse? !uring
urination? !uring )assing stools?#ndometrial ca-!id u notice any bleeding after intercourse?
Orthostatic hy)otension-difficulty breathing, di33iness, lightheadedness, heart racing, chest )ain
>
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O%-ha/e u e/er been )regnant before? !o you ha/e any kids? Ho+ are they deli/ered?
!id u ha/e any com)lication during )regnancy? !uring deli/ery?
!id you ha/e any miscarriages?
F 0 1 & &thyroidR; &tumorR;
A H 4 " FO blood thinnersR;
Fbleeding disorders, multi)le abortionsR;
cocaine/asoconstrictionabortionR;
Closure and Ad/ice: t has di33iness-
our condition a))ears to be an emergency for me. lease dont take anything by mouth until the
in/estigation results are out. y nurse +ill be checking for your /itals regularly.
It can be due to com)lication of unkno+n )regnancy, abnormal hormone le/els or any infection.
aintain genital hygiene )ractice safe se6;, take )lenty of fluids, take ade=uate rest
!ont in/ol/e in acti/ities that increase discomfort
Iron and calcium su))lementation
A%EO$$HOEA
!2!: &AA or A
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erimeno)ause and remature o/arian failure- do u ha/e any hot flashes? Any night s+eats? !id
u notice any mood changes recently2 do u feel irritable? any )ain during intercourse? Any dryness
in your )ri/ate )arts?
rolactinemia do u ha/e any headache? Any /ision )roblems? any ni))le discharge?
CO!-did u notice any e6cessi/e hair gro+th on your face?
&hyrod- Js
Anore6ia ner/osa- any +eight changes?
remature o/arian failure and )erimeno)ause- any hot flashes? !ryness in )ri/ate )arts?
!e)ression?-if mood good then ask IC#. If bad ask I"#CA
ost )ill amenorrhea-are you using any OCs?
#6amination:%elly
Occular m/nts,/isual fields-)ituitary tumors,hy)er)rolactinoma;
$efle6eshy)othyroidism;
el/ic e6am- In the later )art of the day
Closure and ad/ice:
#6ercise to reduce +eightCO!;
Calcium and iron su))lementation
In/ol/e in )leasurable acti/itiesmeno)ause;
CJ:
4n)lanned )regnancy?I understand your an6iety about this un)lanned )regnancy. I ad/ice you to discuss this +ith your
husband. As your )hysician, I +ant to assure you that I am here to su))ort and ad/ice you
regardless of the decision you make. If you +ish, I +ould be ha))y to discuss your o)tions +ith
both of you.
Can I take H$&?I can understand your concern. Once the results are out, I +ill be in a better )osition to tell you
+hat e6actly is causing your )roblem. If your condition re=uires H$& then I +ill be more than
ha))y to )rescribe it to you.
>
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)A#IA! DISCHA$#E
!2!:
%acterial /aginosis
Candidial /aginitis&richomonas /aginitis
Cer/icitisChlamydia and gonorrhoea;4rethritis
I!
(orku):
el/ic e6amination
(etmount and 8OH )re)aration of /aginal discharge
Cer/ical cultures, 0AA&, 4! abdomen
4rine for C2
4rine for %HC"
! O # F C A A A
C A % C O!o u ha/e any ulcers in your )ri/ate )arts? any dryness of your )ri/ate )arts? any itching of your
)ri/ate )arts?
!o u ha/e any )ain during intercourse?
4rethritis-do you ha/e any % F 4 0 H I ?
%-burning, Fre=uency, urgency, nocturia, stream2strain, incom)lete e/acuation, )ain or )us
"onorrhea- do u ha/e any rash on your skin? Any 9oint )ains?
F 0 1 & & &&any trauma to your )ri/ate )arts?;
edications-any OC )ills or any steroid use?
#6amination:
%elly e6, C1A tenderness of 4&I
"#-look for mouth ulcers or sores
Closure and ad/ice:
It could be due to an infection of your )ri/ate )arts or infection of your urinary tract or anycom)lication of )regnancy.
aintain )ro)er hygiene of your )ri/ate )arts+ash regularly and kee) it dry;
ractice safe se6ual methods
&ake )lenty of fluids, nutritious diet, ade=uate rest
If #$ case: your condition seems to be an emergency. lease donot take anything by mouth untilthe instructions are )assed. Once I am done +ith this, I +ill send my nurse to monitor your /itals
and gi/e you I1 fluids and a))ro)riate medications.
>B
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D"SPA$E(IA
!2!:
1ul/odynia
1aginismusAtro)hic /aginitis
Cer/icitis#ndometriosis
I!
!e)ression
!omestic /iolence
(orku):
el/ic e6am
8OH and (etmount )re)aration
Cer/ical cultures
42 )el/is
la)rosco)y
! O # F C A A A and ! 4 ! I
F 0 1 & & & and A H 4 " F O
! 4 ! I
!o u ha/e any discharge? Any ulcers? Any itching? Any dryness in your )ri/ate )arts?
!o you ha/e any belly )ain?for cer/icits, endometriosis, and I!; and ask for these res)ecti/e
sym)toms
Are u safe at home?
Ask for mood and relations
Closure and ad/ice:
CJ: +hy are you asking me this =uestion are u safe at home?;
I am concerned that domestic maybe in/ol/ed and my goal is to make sure that you are in a safeen/ironment and not a /ictim of abuse.
>
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SAPPI# Bein, irrita3le .or silly t4in,s
!!: code "HAO
eno)ause
"A!generali3ed an6iety disorder;Hy)erthyroidism
Anemialee) disorder, se6ual )roblem
Occult malignancy
(orku):
erum 'H, FH
erum &>, &, &H le/els
C%C, #$, electrolytes
erum iron studies and H%
eno)ause-Ask for meno)ause sym)toma
"#!-are u an6ious about anything? !o you ha/e any stress in your life?
Anemia- do you ha/e any bleeding )oints? Any racing of heart? Any di33iness?Hy)erthyroidism? Any e6cess s+eating? Any shaky m/ts in hands? Any irritability? Any )roblem
ad9usting to surrounding tem)? Any a))etite and +eight changes?
Occult malignancy-any a))etite and +eight changes recently?
lee) disorder-do you snore? &otally, ho+ many hours do you slee)?(hom do you li/e +ith? Ho+ is your relationshi) +ith them?
"#:
&hyroid and )ulses
C1
'ungs
!&$ increased in hy)erthyroidism
Closure and ad/ice:
It may be due to hormonal changes or normal changes +ith aging?
%e in/ol/ed in )leasurable acti/ities
)end time +ith your lo/ed onesfriends and family;
&ake iron and calcium su))lementationIf stress )resent, a))ointment +ith stress counselor
>D
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ICOTIECE
!2!: code O40!
-stress incontinence
O-o/erflo+ incontinence4-4&I, urge incont
0-0ormal )ressure hydroce)halud!-! and !I
(orku):
el/ic e6am
Cystogram
4rodynamic study
4A and culture
Jti) test
C& head
$% H%A7C
! O # F C A A AF-ho+ often do you ha/e these accidents? Is there any s)ecific time or e/ent associated +ith
these accidents?
!oes it affect your daily acti/ity?
!oes it affect your se6ual life?!oes it affect your inter)ersonal relationshi)s?
!o u use any absorbent )ads? If yes, ho+ many?
Ask for %F40HI but dont ask for stream;
!o u ha/e any /aginal discharge?
!id u e/er thro+ a fit? Any headache? Any +eakness of your limbs?-0H
!o u ha/e any increased fre=uency of your urination and ho+ is your thirst?-!
F 0 1 & & & &&-any trauma to your back or )ri/ate )arts?
O%:
Ho+ many )regnancies did you ha/e? (hat +as the mode of the deli/ery? Force)s or 01! or
C?
Closure and ad/ice:
#m)ty your bladder as fre=uently as )ossible.
&ry to take an aisle seat +hile you tra/el
Cut do+n on your alcohol and caffeineI ad/ice you to use absorbent )ads.
(ith your )ermission I +ould like to a))oint a )hysiothera)ist +ho can teach you somestrengthening e6ercises for you )el/ic muscles and I +ill be there through the )rocedure.
>E
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I%POTECE or SE5(A! D"S*(CTIO
!2!: code !HA&
!-!, drugs%eta blocers, diuretics;, de)ression
-stress induced, stroke-)erformance an6iety, )ost I, )ituitary dysfunction
H-htnA-atherosclerosis
&-trauma to back
(orku):
"enital and rectal e6am
%, C%C
tam) test
li)ids, )el/ic !o))ler
&estosterone
$%
! O # F A AF-do u ha/e this )roblem e/ery time you )erform se6?
Ho+ is your desire?
On a scale of 7 to 7K, +ith 7 being flaccid and being 9ust able to )enetrate, ho+ do u grade your
erection?!o u ha/e any )roblem +ith e9aculation?
!id u obser/e early morning erections? if yes-)erformance an6iety;
Are u an6ious about se6?
(ho is your )artner?
!o u ha/e any other )artners? If yes, do you ha/e this )roblem +ith all the )artners?
If no, ho+ is your relationshi) +ith your )artner?
Ask for ! 4 ! I sym)toms
ituitary- do u ha/e any headache? Any /ision changes?
C0-do u ha/e any +eakness or numbness or tingling any+here in your body?
A0-do u )ass urine +ithout your kno+ledge? !o you )ass stools +ithout your kno+ledge?
Atherosclerosis-do you ha/e any )ain in your legs +hen +alking?
!e)ression-ho+ is your mood? If good, ask for I"#CA
F 0 1 & & &&-any trauma to your back or )ri/ate )arts?
!o you any stress at +ork?
!o you use 1iagra or sildenafil?
#6amination:
C1-back
C0- 'o+er limbs-$
>
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PEDIAT$IC CASES
For an emergency case child is in #$ and mother in e6aminees room;
CJ: doc, my child is in #$. 'ets go and see my child no+.I am really /ery sorry that your child is in #$. I can understand that you are /ery an6ious about
your childs health, but donot +orry, your child is in safe hands. (e ha/e a /ery good intensi/e
care team at our hos)ital +ho +ill take care of your child /ery +ell. our emotional stability is
/ery im)ortant for your childs health, )lease be strong.
&o kno+ more about your childs )roblem, I +ould like to ask you fe+ =s and +rite do+n notes
+hile +e talk. I assure you that I +ill be as =uick as )ossible. o )lease bear +ith me for some
time. As soon as I am done +ith my =s, I +ill go and e6amine your child )ersonally. Is that ok
+ith you? hall I )roceed?
Ok s.*, I am !r.$a/i the attending )ediatrician at this medical center and I +ill be taking care
of your child today5555..
(hat is your childs name? ho+ old is he2she?
ay I kno+ +hy is he in the IC4?
other gi/es com)laint55..ho+ em)athy5555..
Can you tell me more about your childs )roblem?
! O # C F A A A
Child at home and mother in room:
Hello s.*, good morning. I am !r.$a/i, the attending )ediatrician at this medical center. 0ice
to meet you.
(hat is your childs name? ho+ old is he? (here is he right no+? (ho is taking care of him?
Ok s.*, ho+ can I hel) you?
other gi/es com)laint5555.
"i/e em)athy5555..Can you tell me more about your childs )roblem?
! O # C F A A A
CJ: doc, +hy are you so late. I ha/e been +aiting for you since a long time.
I am /ery sorry for the delay s.*. I +as encountered +ith some une6)ected delay. 0o+ I am
here +ith you and I assure that I +ill gi/e my uninterru)ted attention.
*E)E$
hone case:
Hello, I am dr.ra/i, the attending )ediatrician2)hysician at this medical center and I +ill be taking
care of your call today.
ay I kno+ +ho I am s)eaking to? Ho+ is he2she related to you? (ith +hom is the baby staying
+ith?
Ok s.6, ho+ can I hel) you?
I am sorry to hear your childs )roblem. I +ill do my best to hel) your child in this regard. For
that I need to ask fe+ =s and make a short note +hile +e discuss. Is that ok +ith you?
K
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s.*, if there is a )ause in my con/ersation, )lease understand that I am making a note. o
)lease dont hang u) the )hone.
(hat is your childs name? Is it a baby boy or a girl?
Ho+ old is your child?
(here is the child no+?Can you tell me more about your childs )roblem?
Fe/er:
!id you record the tem)erature? If yes, may I kno+ the reading? If no, is it lo+grade or high
grade?
Is it associated +ith any chills or rigors?
Is it associated +ith any s+eating?
!id you inter/ene in any manner? any medication like &ylenol?
4$&I:
!oes he ha/e any runny nose?
Any cough?
Any fast breathing?
Any ear discharge or ear )ulling? If yes, does he ha/e any hearing )roblem?Any +atering from eyes?
Any difficulty s+allo+ing?
$ash:does he ha/e any rash? If yes, +here and ho+ does it look like?
!iarrhea or /omiting:
Code O0CA''I!IO&
O-Onset,
0-number,
C-cry2cough2consistency,
A-associated sym)s-eg:4$&I sym)s,rash,etc.,
'-listlessness,'-li=uids-urine and intake out)ut,
I-immuni3ation,
!-diet,dehydration,de/elo)ment,daycare, doctor /isit
I-infections in family or ill contacts
O-O$
&-tra/el
"I&:stools-ho+ many stools does he )ass )er day?
Ho+ many soiled dia)ers do you change )er day?
!id u see any blood in it?!id u see any +orms in it?
(hats the color of the stools?(hats the consistency? +atery2semisolid;
Is it foul smelling?
!oes he cry +hile )assing stools?
!id he /omit or thro+ u)?
Is there any difficulty +ith s+allo+ing?
!id u notice any belly distension?
7
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!oes the child seem to be ha/ing any belly )ain? like, does he hold his belly +hile crying?;
4rine:
did u notice any change in his urinary habits?
Ho+ many +et dia)ers do u change )er day?(hat is the color of the urine?
!oes he cry +hile )assing urine?
ei3ures:
!id u notice any shaky m/nts of the body?
!ehydration:
!id u notice any dry mouth or dry skin?
!id u notice any sunken eyes?
!id u notice any sunken soft head on his head?
Ho+ is his skin turgor? Is it moist or dry?
Acti/ities:
Can u tell me more about his acti/ities?!oes he look acti/e and )layful2dull and lethargic2irritable?
If dull, is he a+ake and res)onsi/e?
Food:(hat kind of food do u gi/e him?
Is there any change in his food recently?
Ho+ is his a))etite?
!id u notice any changes in his +eight?
A H 4 " F
& % I I ! # $ &-did he tra/el any+here recently? (as your child e/er in9ured?
%-birth history:0o+ I +ould like to ask you fe+ =s regarding little 9ohns birth.Is that ok +ith u?
!uring )regnancy;-did u smoke? !rink alcohol? 4se ilicit drugs during )regnancy?
!id u ha/e routine checku)s during )regnancy? Ho+ often?
!id you take 1& su))lements and /accine shots during )regnancy?!id u ha/e any com)lications during )regnancy? !eli/ery? Or after deli/ery?
(as you )regnancy full term? Or )reterm? Or delayed?
(as it a 01! or C?
After birth;-!id the baby cry after birth?(hen did u start breast feeding?
(hen did he )ass his2her first stool?(hen did he )ass his first urine?
!id he ha/e any medical )roblems after birth?
I-are all your childs immuni3ations2shots u)to date?
I-does he ha/e any ill contacts?
!-is your childs de/)tgro+th and height; in )ar +ith the children of same age?
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!o you send him to daycare?
(hen +as his last doctors /isit? If yes, may I kno+ the reason?
#-ask for acti/ities =s
$-ask for any rash
-ho+ is his slee)?
FH:Are there any smokers around the child?
Is the child safe at home? child safety =s;- break the confidentiality and in/ol/e the child
safety team
Closure and ad/ice:
s.*, from the information you ha/e gi/en me, I am concerned that your childs fe/er maybe
due to infection in his u))er air+ays or lungs or bo+el acc to scenario;. Ho+e/er, it is /ery hard
for me to assess her o/er the tele)hone and I dont +ant to 9eo)ardi3e her health in any+ay.I
+ould like you to bring in your daughter2son to the medical center for a )hysical e6amination and
a full assessment. (e +ill then )roceed accordingly and at that time I +ill be in a better )osition
to tell you +hat e6actly is going on +ith your child.
ean+hile, )lease look for the +arning signs like- fe/er M7K
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*E)E$ &ITH $(" OSE AD IC$EASED B$EATHI#
!2!: (orku):
1iral 4$&I hysical e6am
neumonia C%C +ith !C, electrolytesOtitis media %lood for C2, throat s+ab C2
e)ticemia neumatic otosco)yeningitis ' +ith o)ening )ressure and CF analysis
Occult bacteremia C*$
42A, C2
A(DICE
!!: (orku):
#arly onset P7+k- hysical e6amination
hysiological 9aundice C%C, #$, eleclyts,H%
%reast feeding 9aundice total bil, !% and I!%
A%O2$H incom)atibility %lood grou) and ty)ingLaundice of )rematurity !irect coombs test
0eonatal se)sisif mother had any infection or any ne+ born inf.; %lood for C2, C$
ce)halhematoma
Familial neonatal hy)erbilirubinemia
'ate onset M7+k-
%reast milk 9aundice
etabolic causes-hy)othyroidism, galactosemia
C2O discoloration
! O #Color changes:
(hen did you first notice it? P
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!id u notice any belly distension?
%reast feeding:
Are u breast feeding the child?
(hen did you first breast feed your child?Ho+ often do you breast feed your child?
Ho+ long do you breast feed each time?Is he sucking +ell?
Is he also bottle fed? If yes, do you gi/e formula milk or co+s milk?
A%O incom)atibility:
(hat is your blood grou)? our husbands? our childs?
!id you become )regnant before? !id you ha/e any miscarriages?
!ehydration:
!id u notice any dry mouth or dry skin?
!id u notice any sunken eyes?
!id u notice any sunken soft head on his head?
Ho+ is his skin turgor? Is it moist or dry?
Acti/ities:
Can u tell me more about his acti/ities?
!oes he look acti/e and )layful2dull and lethargic2irritable?If dull, is he a+ake and res)onsi/e?
Fe/er:
!oes he ha/e any fe/er? Any shaky m/ts of his body? kernicterus;
!id you notice any rash on his body?
$O:
!oes he ha/e any runny nose? Cough? Fast breathing?!id you notice any ear discharge? #ar )ulling? (atering from eyes?
A H 4 "
A F F-acti/ity, feeding, sucking, family
Family-ho+ many siblings does little 6 ha/e? Ho+ are they doing? !o you send your children todaycare?
& % I I ! # $
&-did he tra/el any+here recently? (as your child e/er in9ured?
%-birth history:0o+ I +ould like to ask you fe+ =s regarding little 9ohns birth.Is that ok +ith u?
!uring )regnancy;-did u smoke? !rink alcohol? 4se ilicit drugs during )regnancy?
!id u ha/e routine checku)s during )regnancy? Ho+ often?
!id you take 1& su))lements and /accine shots during )regnancy?
!id u ha/e any com)lications during )regnancy? !eli/ery? Or after deli/ery?
(as you )regnancy full term? Or )reterm? Or delayed?
(as it a 01! or C?
After birth;-!id the baby cry after birth?
B
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(hen did u start breast feeding?
(hen did he )ass his2her first stool?
(hen did he )ass his first urine?
!id he ha/e any medical )roblems after birth?
I-are all your childs immuni3ations2shots u)to date?
I-does he ha/e any ill contacts?
!-is your childs de/)tgro+th and height; in )ar +ith the children of same age?
!o you send him to daycare?
(hen +as his last doctors /isit? If yes, may I kno+ the reason?
Closure and ad/ice:
&hankyou for ans+ering all the =s )atiently. 0o+ I +ould like to summari3e +hat you ha/e told
me.
After summary-ask is that all or do you +ant me to add anything to this?
0o+ I +ould like to gi/e my im)ression:%ased on the information gi/e by you, I think your childs )roblem could be due to )hysiological
9aundice, +hich is a natural condition seen in infants and gradually disa))ears by 7 to < +ks.
Ho+e/er, there are also other )ossibilities like 9aundice due to breast feeding or blood grou)
mismatch or birth defects or some other )athological conditions +hich needs to be ruled out.
Ho+e/er, it is /ery hard for me to assess her o/er the tele)hone and I dont +ant to 9eo)ardi3e
her health in any+ay. I +ould like you to bring in your daughter2son to the medical center for a
)hysical e6amination and a full assessment. (e +ill then )roceed accordingly and at that time I
+ill be in a better )osition to tell you +hat e6actly is going on +ith your child.
ean+hile, )lease look for the +arning signs like- fe/er M7K
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ST$IDO$
!!: code FC'#A$
Foreign body obstruction
Crou)'aryngitis, laryngomalacia
#)iglottitisAngioedema
$etro)haryngeal abscess
(orku):
hysical e6am
A%" analysis
C%C
*ray neckA and lateral;
C*$ A /ie+ in e6)iration;
!irect laryngosco)y and bronchosco)y
Child in #$:I am really /ery sorry that your child is in #$. I can understand that you are /ery an6ious about
your childs health, but donot +orry, your child is in safe hands. (e ha/e a /ery good intensi/e
care team at our hos)ital +ho +ill take care of your child /ery +ell. our emotional stability is
/ery im)ortant for your childs health, )lease be strong.&o kno+ more about your childs )roblem, I +ould like to ask you fe+ =s and +rite do+n notes
+hile +e talk. I assure you that I +ill be as =uick as )ossible. o )lease bear +ith me for some
time. As soon as I am done +ith my =s, I +ill go and e6amine your child )ersonally. Is that ok
+ith you? hall I )roceed?
Ok s.*, I am !r.$a/i the attending )ediatrician at this medical center and I +ill be taking care
of your child today555555
(hat is your childs name? ho+ old is he2she?ay I kno+ +hy is he in the IC4?
other gi/es com)laint55..
ho+ em)athy5555..
Can you tell me more about your childs )roblem?
! O # F A A#-+hat +as he doing +hen it started?
F-is the sound consistently there or does it come and go?
Associated =s:Code %I"!CH
%-+hen is it better heard? (hile breathing in or out? Is there any breathlessness? Any bluishdiscoloration?
I-did you inter/ene in any +ay? Any h2o intubation?
"-guraka-does he snore +hile slee)ing?
!-any drooling or difficulty in s+allo+ing?
C-any cry or cough?
H-any hoarseness?
D
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Ask for &%I!!#$:
%irth, immuni3ation, diet, daycare, de/elo)ment, doctor /isit
Ask for any rash and s+elling of face-hereditary angioedema;
Closure and ad/ice:If its a )hone case-s.6, according to the information gi/en by you, I am considering a
)ossibility of foreign body as)iration. Ho+e/er, there are se/eral other )ossibilities that need to
be ruled out and I feel that she needs emergency medical attention. o I suggest you to call 77
immediately and bring her to the medical center.
ean+hile, I ad/ice you not to attem)t to remo/e the foreign body because this may cause it to
become more dee)ly lodged, if it is actually )resent.
In case, if you notice any choking or res)iratory com)romise, )lease )erform a heimlichs
maneu/er by thrusting tummy +ith sudden )ressure.
PIC1" EATE$
!!:
Habitual eating disorder'o+ fiber diet
'ead )oisioning
Iron deficiency anemia
arasitic infestation
Hy)othyroidism
O))osition defiant disorder
A!H!
(orku):
hysical e6am
C%C, serum electrolytes
erum lead le/els
tool for o/a and )arasites
erum &Herum iron studies
Hello, I am !r.$a/i. I am the attending )ediatrician a this medical center. ay I kno+ +ith +hom
I am talking to?(hat is your relationshi) +ith the child?
Its nice to talk to you. Ho+ can I hel) you?he gi/es the com)laints5555..
I am sorry to hear that s.6. I +ill try my best to hel) you out in this regard555..
(hat is your childs name? Ho+ old is he?
(here is he? (hat is he doing no+?
(hy do you think he is a )icky eater?
!oes he ha/e any s)ecific )references for the food?
E
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! O # F since ho+ long has he been ha/ing this )roblem? Ho+ it is )rogressing?is it getting
+orse or getting better?; does he constantly beha/e like that? ho+ fre=uently does he eat?
%eha/ior:
Ha/e you e/er )unished or re+arded your child to alter his eating beha/ior?!oes he +atch t/ +hile eating?
!oes he follo+ his schedule of meals?!oes he often drink high calorie drinks like sodas, 9uice or milk?
!o you offer any desserts +ith regular meals?
%o+els:
!oes he ha/e any belly )ain?
Any )roblems +ith bo+el m/ts? If yes, ho+ many times a +eek does he ha/e his bo+el m/ts? if
P> stools )er +eekconsti)ation. If for Myrs;
Ho+ long does he sit on the toilet?
!oes he resist toilet training?
!oes he a/oid toilet because of acti/ities such as )laying?
Family:
Ho+ many children do you ha/e?
Ho+ much time do you s)end +ith them?
(ho takes care of them +hen you are +orking?
!oes he go to daycare? If yes, does he ha/e any ill contacts there?
Ask for any other associated sym)s: 4$&I, diarrhea sym)s
'ead )oisioning- +hat kind of house do you li/e in?/ery old one?;
&em)er tantrum /s. A!H!:
Is the child easily distractable?
!oes he ha/e any difficulty +ith conc and focus?
Ho+ is his memory?!oes he ha/e any )roblems organi3ing ideas and belongings?
!oes he sho+ any im)ulsity?
!oes he ha/e +eak )lanning and e6ecution?
& % I I ! # $
A H 4 " F
Closure and ad/ice:
rs.*, According to the information you )ro/ided me, I feel that your son is )robably )assing
through a normal )hase of gro+th. It is a common )roblem in this age grou). Fortunately, it
res)onds +ell to a fe+ beha/ioral changes.
First of all, I +ould suggest you to strictly follo+ a set schedule and offer him /ariety of foods at
meal time.
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!iscourage high calorie drinks b2+ meals
0e6t im)ortant thing is en/ironment at meal time. It should be )leasant +ithout any distractions.
Any argument or +atching t/ should be a/oided at the same time.
$egarding the consti)ation, I +ould suggest you to )ro/ide him high fiber diet like cereals and
/egetables. #ncourage him to follo+ a scheduled time to sit on the toilet by re+arding him.Ho+e/er, I need to e6amine him )ersonally and run do+n some tests to rule out some other
)ossible causes of consti)ation and beha/ioral disorders before I make a definiti/e diagnosis andgi/e you my o)inion.
!oes that sound good to you?
I ho)e you understand +hat +e discussed today.
!o you ha/e any =uestions for me?
Ok then, I +ill be looking for+ard to see you at the hos)ital. &ake care and bye bye.
EE($ESIS