Total time is 25 minutes / 12 stations: - 15 minutes Hx and PE + 10 minutes patient notes - Doorway information è 10-20 seconds - History taking è 8 minutes - Physical examination è 5 minutes - Closure è 2 minutes - Patient Notes (PN) è 10 minutes - ALWAYS Eye contact è done answer any Qs while you are washing you hands - Show Empathy and address his concerns è “This must be a difficult time for you,” or “I can only imagine what you are going through.” // If coughing hardly give him water OR tissue - Address Emotions such as anger, fear, sadness, and anxiety Doorway Information: - NAME, Age, sex and chief complaint - Vitals History Taking: è sitting OR standing - Knock the Door - Are you MR. Or Mrs. ……… ? èIf the pt didn’t respond to his name, maybe there is change in mental status - Hi, I am Dr ……….. ( Shake hands) - I am the Dr who will be taking care of you, I will ask you some Qs then do PE., is that OK with you ? - COVER with a Drape - Then start the History taking History taking components: - Chief complaint - HPI - ROS - PMHx - PSHx - PFHx - Social Hx If Female: - Gyne/Obstetric Hx If child: - Birth Hx - Developmental Hx - Immunization Hx - Feeding Hx History taking Chief Compliant - What brought you here today ? History of Presenting Illness (HPI) PAIN: CC. Sx: 1. When ? 2. Events ? Preceding factors ? 3. Where ? 4. Radiation ? 5. Duration ? 6. Severity ? 7. Describe the pain ? 8. Progression? 9. Frequency ? 10. Intermittent ? Constant ? 11. Timing ? Diurnal variation ? 12. Pain Wakes you up ? 13. Worsening factors ? 14. Alleviating factors ? 15. Previous episodes ? REPEAT SAME QUESTIONS ? Associated Sx: Review of Systems (ROS) General: 1. Fever ? Chills ? Night sweats ? 2. Changes in weight ? 3. Changes in appetite? 4. Fatigue ? Lethargy ? Irritability ? 5. Sleeping ? 6. Concentration ? CNS: - Headache ? - Dizziness ? - Seizures ? - LOC ? - Weakness ? - Numbness ? - Drooling ? - Speech difficulty ? EYE: - Change in vision ? - Double vision ? MOUTH: - Oral ulcers ? - Oral thrush ? - Sore throat ? - Hoarseness ? NECK: - Palpable masses ? CHEST: - chest pain ? - Cough ? - Shortness of breath ? - Palpitations ? - Hemoptysis ? ABDOMEN: - Pain ? - Dyspepsia ? - Change in bowel habits ? - Nausea ? Vomiting ? - Distention ? - TENESMUS ? - DYSCHAZIA ? GENITOURINARY: - Dysuria ? - Urgency ? - Frequency ? - Hematuria ? - Dribbling ? - Straining ? - Weak stream ? - Nocturnal ? - Discharge ? - Ulcers ? EXTREMITIES : - Rashes ? - Cyanosis ? - Edema ? JOINTS and MUSCLES: - Joint pain ? - Bone pain ? - Muscle pain ? Past Medical History (PMHx) - Same problem before ? - Any diseases ? - Any hospitalizations ? - Blood transfusions ? - Medications ? - Compliance ? who gives the medicine ? Side effects ? - Are you taking any over-the-counter drugs, vitamins, or herbs? - Allergies ? Past Surgical History (PSHx) - Any surgeries before ? Past Family History (PFHx) - Any one in the family has or had similar complaint ? - Parents alive? - If alive, health issues ? - If dead, reason for death and at what age? Social history - Attend NURSERY ? SCHOOL ? UNIVERSITY? - Job ? - Any issues at school ? At work ? - Are you exposed to any environmental hazards at work? - Married ? - Children ? - Living with ? - Sexually active? - With men, women or both ? - How many partners ? - Use Contraception? Condoms ? - Any problems with sexual function ? Desire ? Erection ? - If yes, ask about mourning AND night erection ? Libido ? - Any STD before? - If yes, partner was treated ? - HIV test before? - Where are you living ? - With whom ? - Any issues at home ? - Diet ? - Exercise ? - Coffee intake ? - Are you smoking? - How many packs per day ? - How long have you been smoking ? - Have you thought of Quitting ? - Do you want to Quit now ? - If Yes è I would like to make a FU appt after 2 weeks with you ? - If No è - Do you Drink Alcohol ? - How much per week ? - How much per day ? - CAGE ? - Have you thought of Cutting Down ? - Have been Annoyed by people criticizing you ? - Have you ever felt Guilty ? - Have ever had an Eye Opener drink ? “Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? - Do you use any recreational drugs like Marijuana ? - What substances you use ? - Smoke or Inject ? - How often ? - Last time you used it ? - Have you been traveling recently ? - Immunization before travel ? Gynecological/Obstetric history Gyne: - Age of first menstrual period ? - How frequently you get your periods ? - How long does it last ? - Paces per day ? - Regular ? - Pain with periods ? - LMP ? - Spotting in between ? - Vaginal discharge ? - If yes, Color ? Amount ? Smell ? Itching ? Redness ? - Pain with intercourse ? Postcoital bleeding? - PAP smear before ? - Sexual hx? Contraception ? Obs: - Pregnant before ? How many times ? Type of delivery ? - Abortions ? - If pregnant, ask about whether it is Planned ? Desired ? - If unplanned or undesired è ask about DOMESTIC VIOLENCE ? - Then ask about symptoms of pregnancy ? è - Breast discharge and tenderness? - SOB ? - Abdominal pain ? - Nausea and vomiting ? - Urinary symptoms ? - Skin changes ? - Changes in weight ? Appetite ? Fatigue ? - TAKING MULTIVITAMINS ? If child add these: Birth History: - Full term ? - NVD or C-Section ? - Birth weight ? - Regular follow up during pregnancy ? How often ? - Did you have US ? - Any complications during pregnancy ? During delivery ? After delivery ? - Any issues after birth ? - Passed stools ? When ? Developmental history: Immunization history: - Up to date ? - Any reactions ? Feeding history: Special scenarios: DM History: Questions about new onset ? - Urinary frequency? - Eating too much ? - Drinking a lot of water ? - Changes in weight ? - Fatigue ? Questions about Disease Control - For how long you have Diabetes ? - Type I or Type II ? - What medications you are taking for Diabetes ? Names, doses? - If insulin injections ? Where do you inject ? Who injects ? - Compliance ? Any issues with taking the medications or getting the injections ? - How frequently you are having FU apps ? - When was your last visit ? - What was your HbA1C, blood sugar and urine test results that time ? - How do you check your blood sugar ? - How frequently you are checking your blood glucose ? Readings average ? - Last blood glucose reading ? - Episodes of hypoglycemia ? - Social Hx: diet ? Exercise ? Smoking ?.... Questions about Complications - Neurology: headache ? Numbness ? Weakness ? LOC while playing? Any stroke before? - Eye: Any changes in vision ? Do you check your eyes regularly ? When was the last time ? - Chest: Any chest pain ? Hx of angina ? heart attack ? - Abdomen: dyspepsia ? Abdominal pain ? Change in bowel ? - Urinary: dysuria ? Polyuria ? Hematuria ? - Genitalia: any sexual dysfunction ? Vaginal discharges ? - Extremities: skin changes ? Ulcers ? Infections? Numbness? - Symptoms of hypoglycemia ? (Sweating ? palpitations? Dizziness? Seizures ? LOC with playing ? TREMORS ?) - Any admissions due to hypoglycemia or DKA before ? Questions about coping with the disease ? - How do you feel today ? - Depressed ? Stressed ? Anxious ? - Disease coping ? Affecting job ? School ? Parents ? Psychiatric History: Depressed: SIG E CAPS - How long have you been depressed ? - All day ? Day ? Night ? - Sleeping ? - Interest in life ? - Guilty ? - Energy loss, fatigue ? - Concentration ? - Appetite, weight ? - Psychomotor retardation ? - Suicidal ideation ? Suicidal plans ? Suicidal attempts ? DDx Depression: - Major depression disorder ? - Dysthymia disorder ? - Bipolar disorder ? - Normal bereavement ? - Substance-induced mood disorder ? Bipolar: - Flight of ideas ? - Increased energy ? - Sleeping ? - Grandiosity ? Schizophrenia: - Hallucinations ? Visual ? Auditory ? è content ? Do they ask you to harm yourself or others ? - Delusions ?Do you hold beliefs about yourself or the world that other people would find odd? - Disorganized behavior ? - Negative symptoms: social withdrawal ? Flat affect ? MUTE ? DDx Schizophrenia: - Schizophrenia ? - Schizoid personality disorder ? - Substance-induced psychosis ? PTSD: - Nightmares ? - Flash backs ? - Avoidance of stimuli ? Anxiety: - Are you anxious ? - Sweating ? - Palpitations? - Muscle pain ? - Abdominal pain ? Diarrhea ? - SOB ? ALWAYS: - Events leading to that ? stressors ? - Any supporters ? Dementia (Daily activities) - Do you need any help bathing/getting dressed/feeding yourself ? - Do you need any help taking your medications/using the telephone/shopping/preparing food/cleaning your house/doing laundry/getting from place to place/managing money? - Do you need any help going to the toilet? - Do you need any help transferring from your bed to the chair? - Do you ever have accidents with your urine or bowel movements? Abuse: Bruises: - Can you tell me about the BRUISES on your arm ? - Are you safe at home ? - Do you feel unsafe anywhere else ? - Does anyone (your husband/wife/parents/boyfriend) treat you in a way that hurts you or threatens to hurt you ? - Children being abused ? - Any one knows about that ? - Emergency plan? Delay in seeking medical care: - Why the delay ? - Seen by a doctor since then? - Treatment ? - Do you feel safe at home? - Any one harming you ? chest pain: DDx: - Cardiac: angina ? ACS ? Pericarditis ? Aortic dissection ? - Lungs: pneumonia ? Pleuritis ? Pulmonary embolism ? PNEUMOTHORAX ? - Abdomen: GERD ? Esophageal spasm ? - Musculoskeletal: constocondritis ? Fractures ? - Psychological: Panic attack ? - Cocain-induced MI ? Questions: CC. Sx: 16. When ? 17. Events ? Preceding factors ? 18. Where ? 19. Radiation ? 20. Duration 21. Severity ? 22. Describe the pain ? 23. Progression? 24. Frequency ? 25. Timing ? Diurnal variation ? 26. Worsening factors ? 27. Alleviating factors ? 28. Pain Wakes you up ? 29. Previous episodes ? REPEAT SAME QUESTIONS ? Associated Sx: - Fever ? Chills ? Night sweats ? - SOB ? - Wheezing ? - Palpitations ? - Sweating ? - Nausea and vomiting ? - Regurgitation ? - Trauma ? Hematuria : DDx: - Pre-Renal: Bleeding disorder ? Hemoglobinuria ? - Renal: Glumerunephritis ? RCC ? - Post-Renal: UTI ? kidney stones ? Bladder cancer ? Urethral injury ? - Prostate: BPH ? Prostate cancer ? Questions: CC. Sx: - When ? - Events ? - Progression ? - Frequency ? - Relieving factors ? - Exacerbating factors ? - Beginning of void ? Throughout ? End of void ? - Color ? - Mixed ? Streaks ? - Clots ? Associated Sx: - Fever ? - Dysuria ? Urgency ? Frequency ? - Abdominal pain ? - Changes in weight ? - Changes in appetite ? - Trauma ? - Straining ? - Dribbling ? - Weak stream ? - Nocturia ? Any case Genitourinary ask about PROSTATE ? - Straining ? - Dribbling ? - Weak stream ? - Nocturia ? back pain: DDx: - Muscle strain ? - Disc prolapse ? - OSTEOMYELITIS ? - Lumbar spinal stenosis ? - Fracture ? - Osteoporosis ? Stress fracture ? - Cancer metastasis ? - Multiple myeloma ? - UTI ? Questions ? CC.Sx: 1. When ? 2. Events ? Preceding factors ? 3. Where ? 4. Radiation ? 5. Duration 6. Severity ? 7. Describe the pain ? 8. Progression? 9. Frequency ? 10. Timing ? Diurnal variation ? 11. Worsening factors ? 12. Alleviating factors ? 13. Previous episodes ? REPEAT SAME QUESTIONS ? Associated Sx: - NEUROLOGICAL SX: Weakness ? Numbness ? Incontinence ? - Changes in weight ? - Changes in appetite ? - Dysuria ? Frequency ? - Dribbling ? Straining ? Weak stream ? Nocturnal ? - Drugs ? - Trauma ? - Heavy work ? TRAUMA: - What happened ? - Headache ? - Discharge from ears ? Nose ? Clear ? Bloody ? - Blurred vision ? Double vision ? - Dizziness ? - LOC ? - Seizures ? - Weakness? - Numbness ? - Stiff neck - chest pain ? è pneumothorax ? Hemothorax ? Pneumonia ? Rib fracture ? - SOB ? - Fever ? - Cough ? Sputum ? Amount ? Smell ? Color ? Consistency ? - Vomiting ? - Abdominal pain ? - Dysuria? - Hematuria ? - Bone pain ? - Joint pain ? - Any trauma: - Influence of alcohol ? Drugs ? - Last time you ate ? - Pain in the arm? DDx: - Traumatic: Sprain ? Fracture ? Joint dislocation ? - Osteoporosis ? - Rheumatological problems ? Questions ? CC.Sx: 1. When ? 2. Events ? Preceding factors ? 3. Where ? 4. Radiation ? 5. Duration 6. Severity ? 7. Describe the pain ? 8. Progression? 9. Frequency ? 10. Timing ? Diurnal variation ? 11. Worsening factors ? 12. Alleviating factors ? 13. Previous episodes ? REPEAT SAME QUESTIONS ? Associated Sx: - Traumatic hx: Trauma ? LOC ? - Weakness ? Numbness ? Pain anywhere else ? - Rheumatological hx ABUSE // assault : - What happened ? - When ? - Where ? - Do you know them ? - Did you REPORT ? - Physical assault ? - Objects used ? - Sexual assault ? - Objects used ? - Type of assault (oral , vaginal, anal) ? - Ejaculation inside you ? - Condom ? Gyne Hx: - LMP ? - Contraception ? - Vaginal bleeding ? Discharge ? ROS: DDx: - RAPE ? - DOMESTIC VIOLENCE ? - Pregnancy ? - STD ? - Physical assault trauma Management: - Not your fault - REPORT - Pelvic exam ? - Urine B hcg è if POSITIVE è Emergency contraception - Vaginal and cervical swabs (WET mount, KOH test, cultures)è then will give you ANTIBIOTICS - HIV ? Hepatitis ? Syphilis ? - Skeletal survey ? - Forensic exam (sexual assault forensic evidence [SAFE] collection kit)
Calf pain: DDx: - DVT ? PE ? - Myositis ? - Cellulitis ? - Ruptured Bakers cyst ? Questions: - Pain Qs ? Associated: - Fever ? - Trauma ? - Redness ? - Swelling ? - HOTNESS ? - chest pain ? - SOB ? - Recent surgery ? Immobilization ? OCP ? Obesity ? Hoarseness: DDx: - Acute OR chronic Laryngitis ? - Vocal cord papilloma ? - Laryngeal cancer ? - GERD ? - Hypothyroidism ? - Lung cancer ? Questions: - When ? - Events ? - Progression ? - Constant ? Intermittent ? - Relieving factors ? Exacerbating factors ? Associated: - Pain during speaking ? - UTRI ? - Cough ? - Masses in the neck ? - Vocal overuse recently ? - Regurgitation ? - chest pain ? - Hemoptysis ? - Changes in weight ? Changes in appetite ? Fatigue ? Fever ? - Smoking ? Drinking ? - Sx of hypothyroidism ? Neck pain: DDx: - Muscle strain ? - Fracture ? Osteoporosis ? - Degenerative joint disease ? OA? - Disk prolapse ? - Meningitis ? - Pharyngitis ? - Thyroid problems ? - Bone cancer ? Questions: - Pain questions? Associated Sx: - Trauma ? - Osteoporosis: drugs ? DEXA before ? - Joint pain ? - Heavy work ? - RADICULOPATHY: Numbness ? Weakness ? - Fever ? - Stiffness ? - URTI ? Sore throat ? - Swellings in the neck ? Osteoporosis : - Drugs ? - DEXA before ? - Calcium ? Vit D ? Abdominal pain : DDx: - Abdomen: Hepatitis ? Cholecystitis ? Cholangitis ? Gastritis ? Pancreatitis ? Appendicitis ? Gastroenteritis ? UTI ? - Pelvic: Complicated pregnancy ? Ruptures ovary ? Ovarian torsion ? PID ? Questions: - Pain Qs ? Associated Sx: - Association with food ? - What food types ? - N & V ? - Change in bowel ? - Change in color ? - Distention ? - Gyne Hx ? Forgetfulness // confusion: DDx: - Delirium ? è - Dementia ? è Alzheimer ? Vascular dementia ? Alcohol ? HIV ? hypothyroidism ? Depression ? NPH ? Questions: - Events ? - Description ? - When ? - Progression ? - Things that are difficult to remember Associated Sx: - Headache ? Dizziness ? LOC ? FALLS ? HEAD TRAUMA ? - Weakness ? Numbness ? Speech difficulties ? - GAIT ? - Urinary incontinence ? - HIV ? Syphillus ? - Hypothyroidism Sx: - Depression ? ADL Sx: - Do you need any help bathing/getting dressed/feeding yourself ? - Do you need any help taking your medication/ shopping/preparing food/cleaning your house/ getting from place to place/managing money? - Do you need any help going to the toilet? - Do you need any help transferring from your bed to the chair? - Do you ever have accidents with your urine or bowel ? Management: - Take with WIFE ? DAUGHTER ? - Social worker Headache: DDx: - Primary : Tension ? Migraine (complicated or not complicated) ? Cluster ? - Secondary: Sinusitis ? URTI? Dental ? Caffein withdrawal ? Bleeding ? Stroke ? Meningitis ? Brain tumor ? Temporal arteritis ? Pseudotumor celebrity ? Questions: - Pain Qs? Associated Sx: - Stress ? - Aura ? Flash lights ? - N & V ? - Photophobia ? Phonophobia ? - Tears ? Runny nose ? - Facial pain ? - URTI ? - Tooth pain ? - Trauma ? - Fever ? - Neck stiffness ? - Weakness ? Numbness ? - Jaw claudication ? - Blurred vision ? Double vision ? - Caffeine ? VISUAL Hx and P.E è very important in headache: - Blurred vision è Increased intracranial pressure (tumor, bleeding, PC), Temporal arteritis secondary to artery thrombus - Double vision è Pseudotumor celebrity - Light flashes è Aura of migraine (complicated migraine) - Photophobia è Migraine ? Meningitis ? Amenorrhea: DDx: - Pregnancy ? - Hormonal : Hypothyroidism ? Hyperprolactenemia ? - Hypothalamic pituitary access è Hypothalamus: Stress? Depression? Anorexia ? Fat diet ? è Ovary: Polycystic ovary syndrome (PCOS) ? Premature ovarian failure ? - Ashermans syndrome ? Questions: CC.Sx: - Gyne and Obs hx ? - Then: - Sx of pregnancy : Breast tenderness ? N&V ? Skin changes ? - Sx of Hypothyroidism: Cold intolerance ? Dry skin ? Hair loss ? Concentration ? Sleeping ? Constipation ? - Sx of hyperprolactinemia: Nipple discharge ? Loss of libido ? Double vision ? Headache ? - Hx of Stress ? Depression ? Fat diet ? - Sx of PCOS: Hirsutism ? Change in Voice ? Weight gain ? - Sx of menopause: Hot flashes ? Dry vagina ? Sleeping ? Dysparenuria: DDx: - Infections: Vulvovaginitis ? Cervicitis ? - Endometriosis ? - Vulvodynia ? Vaginismus ? - Atrophic vagina ? - Domestic violence ? Questions: - Pain Qs? Associated ? - Gyne hx ? - Depressed ? Anxious ? Stressed ? Menopause Sx ? - Conflicts with husband ? - Physical abuse ? - Safe ? Hearing loss: DDx: - Age related presbycusis ? - Conductive : recurrent OM ? OTOSECLEROSIS ? - Sensorineural: 8th nerve damage ( Exposure to loud noise)+ (acoustic neuroma) ? Ototoxicity ( Aspirin, furosemide, ahminoglycosides, vancomycin) ? Meniers disease ? Questions: - When ? - Events ? - Location ? - Progression ? - Intermittent ? Constant ? - Relieving ? Exacerbating factors ? Associated: - Ear pain ? - Ear discharge ? - Fever ? - Recurrent infections ? - Ringing in the ears ? Tinnitus ? - Dizziness ? Room spinning ? - Trauma ? Management: - Audiometery è hearing assessment - BS auditory evoked potential è 8th nerve neuropathy - CT brain - VDRL è Syphillus Jaundice in newborn: DDx: - Physiologic ? Breastfeeding ? Breast milk ? - Sepsis ? - Hemolysis ? ABO incompatibility ? Rh incompatibility ? G6PD ? - Hypothyroidism ? - Hepatitis Questions: - When ? - Body parts affected ? - Progression ? - Constant ? Intermittent ? - Relieving ? Exacerbating factors ? Associated: - Feeding ? - Irritable ? - Sunken eyes ? Passing urine ? Lethargic ? - Fever ? ROS ? - Blood groups ? - Abdominal distention ? - N & V ? - Change in bowel ? - Color stool and urine ? Acute Vs. chronic cough ? DDx: ACUTE: - URTI - Acute bronchitis - Acute Pneumonia: VIRAL ? Bacterial ? - Pleuritis CHRONIC: - Sinusitis and post-nasal drip - Asthma - GERD - Chronic infections: TB , HIV-associated chest infections - COPD - Bronchiectasis - Lung cancer Questions: CC, hx: - When? - Proceeding symptoms? Events ? - Progression ? - Intermittent ? Constant ? - Diurnal variation ? - Relieving factors ? Drugs ? - Worsening factors ? - Sputum ? - Amount ? - Consistency ? - Color ? - Blood ? If yes, mixed ? Fresh ? - SHOW me a sample ? Associated Sx: - URTI ? - Shortness of breath ? - chest pain ? - Wheezing ? - Fever ? Chills ? Night sweats ? - Exposure to sick pt ? Exposure to TB ? Recent travel ? Last PPD ? - Change in weight ? Change in appetite ? Fatigue ? - Regurgitation ? Heart burn ? - Sexual practices ? Ac Jaundice: DDx: - Pre: Hemolytic anemia ? - Liver: Hepatitis: Due to acute hepatitis OR chronic hepatitis OR DRUG toxicity ? Cirrhosis ? Hepatocellular cancer ? Autoimmune: autoimmune hepatitis + primary biliary cirrhosis ?Genetic diseases: - Post: Obstruction by: Stones ? Pancreatic cancer ? , Infection: Cholangitis ? Questions: - When ? - Events ? Preceding events ? - Progressive ? - Intermittent ? Constant ? - Relieving factors ? Exacerbating ? Associated Sx: - Abdominal pain ? - Abdominal distention ? - N & vomiting ? - Change in bowel ? - COLOR OF STOOL AND URINE ? - Change in weight ? Change in appetite ? FATIGUE ? Fever ? - Pruritus ? - RECENT TRAVEL ? - BLOOD TRANSFUSION ? - RECENT DRUGS ? - ALCOHOL ? Dizziness: DDx: - Vertigo : - Peripheral vertigo : BENIGN POSITIONAL VERTIGO ? Vestibular neuritis ? Labrynthitis ? Meniers disease ? Otolith ? - Central vertigo : BS problems: BS stroke ? - Lightheadedness: heart arrhythmia ? Aortic stenosis ? - Postural hypotension: drugs ? DM ? Questions: - When ? - Describe ? Lightheadedness ? Vertigo ? - Frequency ? - Duration ? - Progression ? - Intermittent ? Constant ? - Diurnal variation ? - Relieving ? Exacerbating factors ? Positions : Lying down ? Standing ? Associated Sx: - Ringing in the ear ? - Hearing loss ? - Fever ? - URTI ? - Ear pain ? - Ear discharge ? - N & V ? - Head trauma ? - Double vision ? Difficulty swallowing ? - Palpitations ? - chest pain ? - Drugs ? DM ? Diarrhea ? - FALLS ? Management: - Be careful while walking - DIX-HALLPIKE MANEUVER ? - Audiometry ? - BSAEP ? Knee pain: DDx: - Traumatic: Fracture ? Ligament tear ? Dislocation ? - Rheumatological : Septic arthritis ? RA ? OA ? SLE ? Questions ? - Pain Qs ? Associated Sx: - Trauma ? - Redness ? - Swelling ? - Stiffness ? - Other joints ? - Fever ? Changes in weight ? Appetite ? Fatigue ? Skin rashes ? Oral ulcers ? Photosensitivity ? Cold Temp causes changes in fingers ? - Hx of TICK BITES ? - ROS ? Heel pain: DDx: - Traumatic: Calcaneus fracture ? Achilles tendinitis ? Plantar fasciitis ? - Rheumatological ? Questions: - Pain Qs ? Associated Sx: - Trauma ? Fatigue: DDx: - Anemia ? Males: Colon cancer, female: heavy menses ? - Hypothyroidism ? - Chronic infection: Hepatitis ? HIV ? - Cancer ? - Depression ? Anxiety ? PTSD ? - DIABETES ? - MYASTHENIA GRAVIS ? Questions: - When ? - Events ? - Progression ? - Constant ? Intermittent ? - Relieving and exacerbating factors ? Associated Sx: - Pale ? - Hypothyroidism Sx: - Sexual hx ? - Transfusions ? - Changes in weight ? Changes in appetite ? Fever ? Night sweats ? - Depressed ? Anxiety ? PTSD ? - Polyuria ? Polydepsia ? - Double vision ? erectile dysfunction: DDx: - Medication side effects : anti-hypertensives - Vascular diseases: DM, HTN, atherosclerosis - Psychological ? - Hypogonadism ? TESTOSTERONE DEFICIENCY ? Questions: - When ? - Mourning or night erections ? - Libido ? - Problems at home ? - Depression ? Anxiety ? - HAIR LOSS ? Sleeping: DDx: - Psychological : Depression ? PTSD ? Anxiety ? - Poor sleep hygiene: drinking a lot of coffee ? Caffeine-induced sleeping disorder ? - Stress-induced sleeping disorder ? - Hypothyroidism OR hyperthyroidism ? - OSA ? Questions: - How much you sleep per night ? - What time you go to bed ? - What do you do before going to bed ? - Difficulty falling asleep ? - Difficulty staying asleep ? - RECURRENT awakenings ? - Nightmares ? - Waking up early ? - SNORING ? - Taking pills to help sleep ? - Sleep all day Associated Sx: - Depression ? - Anxiety ? - Nightmares ? - Stressed ? - Caffeine ? - Hypothyroidism Dx ? Visual hallucinations: DDx: - Febrile hallucinations ? - Schizophrenia ? - Organic causes ? - Substance abuse ? PCP ? Marijuana ? Questions: - When ? - Events ? - What do you see ? - Asking to harm yourself ? - Other hallucinations ? Auditory ? Tactile ? Olfactory ? - How frequent ? - Progression ? - Duration ? - Constant ? Intermittent ? - Relieving and exacerbating factors ? - Do you see them when your eyes are closed ? - Does this happen when you are off drugs ? Associated Sx: - Delusions ? - Disorganized behavior ? - Fever ? - ROS ? - Substance abuse ? Bloody stools: DDx: - Anal fissure ? - Hemorroids ? - Colon cancer ? - Angiodysplasia ? - Colitis ? - Upper GI bleeding ? Peptic ulcer ? Questions: - When ? - Events ? - Fresh ? Color ?Clots ? - Mixed ? Streaks ? - At the beginnings ? Thorough ? End ? - Constant ? Intermittent ? - Frequency ? - Relieving and exacerbating factors ? Associated Sx: - Masses ? - Discharge ? - Abdominal pain ? - Change in bowel habits ? - DYSCHEZIA ? - TENESMUS ? - N & V ? - Change in weight ? Appetite ? Fever ? Fatigue ? Tremors: DDx: - Resting: Parkinson disease - Action: cerebellar disease - Essential tremors - Drugs side effect - Caffein intake - Hyperthyroidism Questions: - When ? - Events ? - Duration ? - Progression ? - Constant ? Intermittent ? - Relieving and exacerbating factors ? Associated Sx: - Gait ? Hand writing ? - ADL ? - FHx ? - Drugs ? - Caffein ? - Hyperthyrodism Sx ? Weight gain: DDx: - Lifestyle ? - Hormonal : hypothyroidism ? Cushing ? - Gyne: Pregnancy ? PCOS ? - Depression ? - Drug side effects ? Lithium ? - Smoking cessation ? Questions: - When ? - How much ? Over ? - Events ? - Pregnancy Sx ? - Hypothyroidism Sx ? - PCOS Sx ? Enuresis: DDx: - Primary è RF: FHx ? Drinking a lot of water ? Stress ? - SecondaryM ? UTI ? DI ? OSA ? Constipation ? Drugs ? Questions about the severity and the causes? - How long ? - Has he/she ever been dry ? - How frequent ? - Day and night ? - What increases or decreases the risk ? - Stress does it increase the risk ? - FHx of enuresis ? - New stressors around ? - Late night eating for drinking ? - What interventions done ? - Punishments ? Rewards ? - Fever - Dysuria - Frequency ? - Hematuria ? - Polydepsia - Polyphasia? - Weight changes ? - SNORING ? - Night awakenings ? - Neurological hx ? Questions about psychological impact ? - How does that affect him/her ? - How does that affect you Seizure in child: DDx: - Febrile seizure: simple or complex - Infantile seizure secondary to meningitis, electrolyte disturbances, hypoglycemia, brain tumor - Head trauma Questions: - Seizure hx ? - ROS ? Sore throat: DDx: - Bacterial pharyngitis ? - Viral pharyngitis ? - Infectious mononeucleousis ? - Acute HIV ? Questions: - PAIN questions ? Associated: - URTI ? - Cough ? - Lymph nodes ? - Sick contacts ? - Abdominal pain ? - Oral ulcers ? - Skin rash ? - Changes in weight ? Appetite ? Fever ? Fatigue ?
Double vision: DDx: - Nerves: Brain mass compressing optic chiasma : prolactinoma, Craniopharyngioma ? - Muscles: Myasthenia Graves ? LOC: DDx: - Seizure ==> secondary to infections, stroke, brain tumor, electrolyte disturbances, hypoglycemia - Head trauma - Cardiac syncope - Vasovagal attack - Postural hypotension ==> drugs, DM, dehydration Questions: - When ? - Events ? - Witness ? Duration ? - LOC after or before you fell ? - Head trauma ? - Pre-ictal Sx: abnormal smell, flashlights ? Pre-syncope Sx: palpitations ? Sweating ? Dizziness ? Nausea and vomiting ? - Vital Sx: Seizure ? Up rolling of the eyes ? Tongue biting ? Urinary incontinence ? - Post-ictal: Confusion ? Headache ? Paralysis ? Associated: - Trauma ? - Fever ? Neck stiffness ? - Palpitations ? Dizziness ? - Weakness ? Numbness ? Speech difficulty ? - Diarrhea ? - Drugs ? Anti-hypertensives ? Loss of vision: DDx: - Acute: Retinal detachment ? Arterial thrombus (Temporal arteritis ? , stroke), ? Vitreous hemorrhage ? ACUTE ANGLE-CLOSED GLAUCOMA ? - Gradual: Cataract ? Glaucoma ? Questions: - When ? - Events ? - Sudden ? Gradual ? - Progression ? - Relieving and exacerbating factors ? Associated Sx: - Flashes of light ? - Photophobia ? Eye pain ? Redness ? Swelling ? Discharge ? Tears ? - Headache ? Jaw claudication ? - Weakness ? Numbness ? Speech difficulty ? - Trauma ? - DM ? - Medications ? Investigations: - Intra-ocular tonometry ? - Fluorescing angiogram ? Weakness// numbness : DDx: - TIA ? - Stroke ? - MULTIPLE SCLEROSIS ? Questions: - When ? - Where ? - DURATION ? - Intermittent ? Constant ? - Progression ? - Exacerbating and relieving factors ? Associated Sx: - Weakness ? - Numbness ? - Speech difficulty ? - Urinary incontinence ? - Headache ? Seizures ? Falls ? Trauma ? - Double vision ? Night sweats: DDx: - Infections: TB ? HIV ? - Cancer: lymphoma (B symptoms ) - Hyperthyroidism ? - Menopause ? Questions: - When ? - Events ? - Only night ? - Intermittent ? constant ? - Progression ? - Relieving and exacerbating factors ? Associated Sx: - Cough ? - chest pain ? - Hemoptysis ? - Swollen nodes ? - Exposure to TB ? - Last PPD ? - Skin rashes ? Oral thrush and ulcers ? - Recent travel ? - Weight loss ? Fatigue ? - Hyperthyroidism Sx: - Menopause Sx ? Palpitations: DDx: - Cardiac arrhythmia ? angina ? MVP ? - Hyperthyroidism ? - Pheochromocytoma ? - Hypoglycemia ? - CARCINOID SYNDROME ? - Drugs ? - Caffeine intake ? - Anxiety ? Panic attack ? Questions: - When ? - Events ? - ONSET AND OFFSET ? - Frequency ? - Duration ? - Intermittent ? Constant ? - Progression ? - Diurnal variation ? - Exacerbating and relieving factors ? Associated Sx: - chest pain ? - SOB ? - Sweating ? - Nausea and vomiting ? - Dizziness ? LOC ? Trauma ? - Flushing ? Diarrhea ? - Sx of hyperthyroidism ? - Anxiety ? Weight loss : DDx: - Cancer ? - Hyperthyroidism ? - Eating disorder ? - Anxiety and depression ? Questions : - When ? - Events ? - How much ? - Progression ? - Relieving and exacerbating factors ? Associated Sx: - Change in appetite ? fatigue ? Fever ? Chills ? - ROS ? - Depression ? Anxiety ? - Hyperthyroidism Sx ? - Eating ? Body image ? Dysphagia: DDx: - Esophageal infection ? - Esophageal webs ? PLUMER VINCEN SYNDROME ? - Esophageal cancer ? - Achalasia ? GERD ? - Esophageal spasm ? - Stroke ? - Systemic sclerosis ? Questions: - When ? - Events ? - Odynophagia ? - Solids ? Liquids ? - Constant ? Intermittent ? - Frequency ? - Progression ? - Exacerbating and relieving factors ? Associated Sx: - Fever ? - Oral thrush ? - Weight loss ? Fatigue ? Change in appetite ? - GERD Sx: regurgitation ? Heartburn ? Hoarseness ? - STROKE Sx: DROOLING ? - Change in. Finger color with cold exposure ? Neck mass: DDx: - TB - Lymphoma ? - Lymphadenitis ? Questions: - When ? - Events ? - Progression ? - Pain ? - Skin changes ? - Exacerbating and relieving factors ? - OBSTRUCTIVE Sx Associated Sx: - Fever ? Night sweats ? - Fatigue ? - Change in weight ? Change in appetite ? - URTI ? Sore throat ? Vaginal discharge: DDx: - Vaginitis ? Infection ? Chemicals ? - Cervicitis ? - PID ? - Foreign body ? Questions: - When ? - Color ? Consistency ? Smell ? Amount ? - Progression ? - Intermittent ? Constant? - Relieving and exacerbating factors ? Associated Sx: - Fever ? - Itching ? - Rash ? - Abdominal pain ? - Foreign body ? Short stature: DDx: - Constitutional ? - Familial ? - Genetics ? - Chronic diseases ? - Hormonal: GH deficiency ? hypothyroidism ? Cushing disease ? Questions: - When ? - Events ? - Birth hx ? - Family hx ? - SEXUAL CHARACTERISTICS ? - ROS ? - Cushing Sx ? Behavioral problem child: - Hyperactivity ? - Concentration ? - Violence ? DDx: Primary: - Age appropriate behavior ? - ADHD ? - Defiant oppositional disorder ? - Conduct disorder ? - Adjustment disorder ? - Mania and depression ? Secondary: Hyperthyroidism ? - Substance abuse ? Questions: - When ? - Describe ? - Progression ? - Intermittent ? Constant ? - Exacerbating and relieving factors ? - Home ? School ? Both ? - New stressors at home ? - School performance ? - Violence ? People ? Furniture ? Thefts ? - Depression Sx ? And mania Sx ? - Hyperthyroidism Sx ? - Substance abuse ? Vaginal bleeding: DDx: GYNE AND OBS CAUSES : - COMPLICATED PREGNANCY ? - Cervicitis ? - Dysfunctional uterine bleeding ? - Fibroids ? - Endometriosis ? - Cervical polyps ? Cervical cancer ? - Endometrial hypertrophy ? Endometrial cancer ? - Atrophic vagina ? Atrophic endometrium ? MEDICAL CAUSES: - Hypothyroidism ? - Trauma ? - Bleeding disorder ? Questions: - When ? - Events ? - Severity ? - Intermittent ? Constant ? - Progression ? - Exacerbating and relieving factors ? - Amount ? - Clots ? - Color ? - Pads per day ? - Fatigue ? Associated Sx: - Gyne hx ? - Abdominal pain ? - Menopause Sx ? - Hypothyroidism Sx ? - Trauma ? - Hx of bruises ? Management : - Urine B hcg - Quantitative B hcg - US abdomen - Cervical cultures - Pap smear If the patient tries to talk too much: - “Excuse me, Mr….., I understand how important those issues are for you, but I’d like to ask you some additional questions about your current problem.” After the History Taking: - Summarize - Do you have any other questions ? Challenging questions: Challenging questions: Do I need antibiotics to get better? Possibly. Antibiotics don’t help with bronchitis because this condition is primarily caused by viruses that are not sensitive to antibiotics. However, if I find that you have bacterial pneumonia, antibiotics will be needed I don’t think I can go to work, doctor. Can you write a letter to my boss so that I can have some time off? You’re right; heavy construction work can worsen your back pain or cause it to heal more slowly. I will ask your boss to reassign you to light duty for a while. Financial issues: Social worker An anxious patient who you suspect has been abused asks, “Why are you asking me these questions?” I am primarily concerned about your safety, and my goal is to make sure that you are in a safe environment and that you are not a victim of abuse. An elderly male patient says, “I think that it is normal at my age to have this problem” (impotence) or “I am just getting old.” “Not necessarily. Age may play a role in the change you are experiencing in your sexual function, but your problem may have other causes that we should rule out, such as certain diseases (hypertension, diabetes) or medications. We also have medications that may improve your sexual function.” “I read in a journal that the treatment for this disease is herbal compounds. “herbal medicines have been suggested for many diseases. However, their safety and efficacy may not always be clear-cut. Let me know the name of the herbal medicine and I will check into its potential treatment role for this dis- ease.” “I am afraid of surgery.” “I understand your feelings. It is normal and very common to have these feelings before surgery. Is there anything specific that you are concerned about?” “My friend told me that you are a very fine doctor. That’s why I came to you to refill my prescription.” “I am happy that you came to see me, but since this is your first visit, I can’t give you a ref i ll without first reviewing your history to better understand your need for this medication. I will also need to do a physical exam and perhaps order some tests.” “I think that life is full of misery. Why do we have to live?” “Life can certainly be challenging. Is there something in particular that is bothering you? Have you thought of ending your life?” You can then continue screening for depression. A very thin patient with weight loss asks, “Doctor, do you think I am too fat?” Even if the patient appears to be thin, do not state as much. Instead, respond by saying, “I cannot tell right now. First I need to determine your height and weight and calculate your body mass index, and then we can let the numbers tell us if you are at a healthy weight Physical examination: - I am going now to examine you, is that OK? - Wash hands - Cover the pt and expose only selected area after taking permission è “Is it okay if I untie your gown to examine your chest? - After examining any area COVER it immediately and say THANK YOU - Then take permission again for the next area - You may ask questions during physical exam è but you need to PAUSE to make Ana eye contact - Forbidden exams: - Corneal reflex, breast, rectal, pelvic, or genital exam - Physical exam: - General inspection - Each: Inspect, palpate, listen OR look - Then thank the patient Physical examination: General inspection: - Distressed ? - Anxious ? Depressed ? Vitals + Growth measurements - Vitals - Orthostatic vitals - Growth measurements - Orthostatic vitals: - Have the patient lie down for 5 minutes. - Measure blood pressure and pulse rate. - Have the patient stand. - Repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes. - A drop in bp of ≥20 mm Hg, or in diastolic bp of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal. HEENT: Head: - Inspect for Signs of trauma (Scars, swellings, raccoon eyes), ( Atraumatic) // Size ( Normocephalic) Eyes: - Inspect the eye for redness ( conjunctivitis) - Pupillary reflexes (Symmetrical and reactive) - Extra-ocular movements - Visual acuity - Fundoscopic examination ( R-R-R) AND (L-L-L) Ears: - Inspect for redness, swelling, discharge - Palpate External ear: tug test AND Mastoid for tenderness - Look with an Otoscope at the Ear canal and ear drum Nose: - Inspect - Palpate sinuses - Look inside at the Turbinates and nasal septum Throat: - Inspect the Lips // oral mucosa for Cyanosis, ORAL THRUSH, rashes and ulcers with a light - Inspect Teeth - Look at the throat Fundoscopic exam: - R-R-R: Stand on the right if you want to examine the right - Put ophthalmoscope on (0) - STABILIZE HEAD - Check for red reflex NECK: - Inspect for any swellings, deformities + JVD - Palpate thyroid and cervical nodes and any obvious mass and trachea - Auscultate over Carotids and thyroid è Use the Bell Thyroid exam: - Hands: tremors ? Sweating ? Palmar erythema ? Pulses ? - Eyes: exophthalmos, lid retraction, EOM + lid lag together (EOMI without diplopia or lid lag) - Neck: inspect for swelling and scars,ask to swallow and to drink water , palpate thyroid and nodes, auscultate while holding breath - Lower limbs: proximal myopathy (squat), ankle jerks HEART: Hand and arm: - Clubbing - Cyanosis - Tar stain - Palpate pulses and comment on them, radioradial ? Radiofemoeal delays? Head: - Eyes: xanthelasma, pallor - Central cyanosis and Tooth decay Neck: - JVD - Auscultate carotids Chest: - Inspect chest for deformities, visible palpation, scars - Palpate apex beat and Locate it + parasternal heave + base of the heart - Auscultate for S1, S1, Murmurs - Auscultate apex WHILE pt in left side and to the base of the heart while pt is leaning forward - Auscultate lung bases Abdomen: - Palpate the liver Lower limb: - Peripheral edema LUNGS: Hand and arm: - Clubbing - Peripheral Cyanosis - Tar stain - Tremors: B2 agonists use - Asterksis: CO2 retention Head: - Central cyanosis Neck: - JVD - Lymph nodes - Trachea Chest: - Inspect chest for deformities, visible palpation, scars - Palpate apex beat and Locate it + Palpate chest for tenderness, chest expansion, Palpate: tactile vocal fremitus - Percussion - Auscultate lungs ( Front and back) - Auscultate for S1, S1, Murmurs ABDOMEN: Hand and arm: - Clubbing - Palmar erythema - HEPATIC FLAP - Spider Nevi Head: - Sclera for jaundice - Mouth for ulcers Neck: - Lymph nodes Chest: - Gynecomastia - Auscultate heart and chest Abdomen: - Inspect : CAPUT MEDUSA, Distention, visible pulsation, scars, Umbilicus - Auscultate BEFORE Palpation, auscultate areas and abdominal Bruit - Palpate lightlyè looking at the face + REBOUND TENDERNESS + Rigidity + Guarding - Palpate deeply è masses - Palpate liver + spleen + kidney Ballotment - Percuss all abdomen then percuss for Liver span And Spleen - If distention è shifting dullness and transmitted thrill - Signs: Obturator sign, Psoas sign, CVA tenderness, Murphys sign - End with mentioning è Rectal exam, Hernial orifices and Pelvic exam Extremities: - Peripheral edema Psoas sign: let the pt raise his leg against resistance Obturator sign: for the leg then INTERNALLY ROTATE THE HIP Rovsing sign: apply pressure over LLQ and release hour hand, if pt feels pain on RLQ, it is positive sign Murphys sign:apply deep pressure below the costal margin then ask the patient to take deep breath in and out è if there is pain he will hold his breath EXTREMITIES: - Clubbing ? Cyanosis ? Edema ? - PALPATE PULSES ? - Rashes ? - Lesions? Nevi è Advice the pt to check it routinely and report any change in it - Bruises ? è Think about Abuse Neurological Mini-mental status exam: - Orientation: Name ? Where ? Date and day ? - Memory: - Immediate memory: Name 3 objects (Pen, bed, chair), then ask the patient to name them again ? - Long-term memory: When did you get married ? - Short-term memory: Rename the 3 objects again ? - Concentration: - Spell WORLD backwards ? - I want you to count backward starting with the number 100 ? - Language: - Point to an object and ask the pt to name it ? - 3 stage-command: take a paper, fold it in half and put it on the table ? - Write a full sentence on the paper ? Neurological exam: - Cranial nerve exam ? - II: Pupillary reflexes, visual fields, visual acuity: cover each eye alone and ask to read, fundoscopic exam - III-IV-VI: EOM - V: sensation to light touch and pin prick, muscle of mastication - VII: close your eyes and open against R, smile, blow - VIII: whisper in the ears, then Rinni and Weber test - IX-X: look at the palate, GAG reflex - XI: shrug your shoulders - XII: tongue out, then tongue on cheeks - Inspect: muscle wasting - Muscle tone: UL: elbow, wrist, LL: left legs and roll them, ankle and CLONUS - Motor: move against Resistance, UL: shoulder abduction and addiction, elbow flexion and extension, wrist flexion and extension, fingers flexion and extension, adduction and abduction // LL: hip flexion and extension, knee flexion and extension, ankle dorsiflexion and plantarflexion, inversion and eversion - Reflexes: Biceps, triceps, brachioradialis, patellar, Achilles, Babinski. - Sensory system: Sharp (pin)/dull (cotton swab), vibration, position sense. - Cerebellum: Finger-to-nose, heel-to-shin, rapid alternating movements, Romberg’s sign, gait: on toes, on heels, heel to toe - Meningeal signs: Neck stiffness, Kernig’s sign, Brudzinski’s sign SCALES: Reflexes (0–4), with 0 being completely areflexic: 1: Hyporeflexia 2: Normal reflexes 3: Hyperreflexia 4: Hyperreflexia plus clonus (test the ankle and the knee) Strength (0–5), with 0 representing an inability to move the limb: 1: Can move limb (wiggle toes) 2: Can lift limb against gravity 3: Can lift limb with one-finger resistance from the examiner 4: Can lift limb with two-finger resistance from the examiner 5: Has full strength Most disk herniations occur at the L4–L5 or L5–S1 vertebral levels. These nerve roots are quickly assessed by checking the knee-jerk reflex (L4), great toe dorsiflexion (L5), and ankle-jerk reflex (S1) Joint pain: Always examine: - Joints above and below - Neurological and vascular exam Shoulder exam: - Inspection: - Inspect and compare the joint with the opposite side, Scars, Deformities, Swelling ? Redness ? Wasting ? - Palpation: - Temperature ? - Bones of shoulder ? - Muscles of the shoulder ? - ROM:COPY WHAT I AM DOING - Active: Flexion, Extension, abduction, adduction, internal rotation, external rotation, adduction and internal rotation (ARMS behind back), abduction and external rotation (ARMS behind head) - Passive: Flexion, Extension, abduction, adduction, internal rotation, external rotation - Special tests: ALL FOR ROTATOR CUFF TEARS - Neers test: abduct the arm and raise it ( Supraspinatous tendinitis) - Hawkin test Drop arm test - Then do neck exam and UL neurological and vascular exam Elbow exam: - Inspection: - Inspect and compare the joint with the opposite side, Scars, Deformities, Swelling ? Redness ? Wasting ? - Palpation: - Temperature ? - Bones of elbow ? - ROM:COPY WHAT I AM DOING - Active: Flexion, Extension, abduction, pronation, supination - Passive: Flexion, Extension, abduction, pronation, supination - Special tests: - Medial epicondylitis: palpate medial bone on forced wrist FLEXION - Lateral epicondylitis: palpate lateral bone on forced wrist EXTENSION - Then do neck exam and UL neurological and vascular exam Wrist exam: HANDS ON PILLOWS - Inspection: - Inspect and compare the joint with the opposite side, Scars, Deformities, Swelling ? Redness ? Wasting ? - Palpation: - Temperature ? - Palpate all joint and bones ? - Hand muscles ? - Palpate pulses ? - ROM:COPY WHAT I AM DOING - Active: WRIST: Flexion, Extension, ulnar and radial deviation, FINGERS: flexion (fist), extension (stretch), abduction and adduction - Passive: WRIST: Flexion, Extension, ulnar and radial deviation, FINGERS: flexion (fist), extension (stretch), abduction and adduction - Special tests: - Tinels test: tap over the median nerve - Phablens test: flex both wrists for 60 seconds the ask if nay numbness - Then do neck exam and UL neurological and vascular exam Hip: LET THE PT SIT THEN STAND: - Inspection: - Inspect and compare the joint with the opposite side, Scars, Deformities, Swelling ? Redness ? Wasting ? - Palpation: - Temperature ? - Palpate all joint and bones ? ASIS ? - ROM: WHILE PRESSING ON ASIS - Active: Flexion, Extension, Abduction, adduction, internal and external rotation - Passive: Flexion, Extension, Abduction, adduction, internal and external rotation - Special tests: - Thomas test: - GAIT ? - Trendelenberg test ? - Then examine: - Joint above and below - Neurological and vascular exam Knee exam: - Inspection: - Inspect and compare the joint with the opposite side, Scars, Deformities, Swelling ? Redness ? Wasting ? - Palpation: - Temperature ? - Palpate all joints and bones ? - Patellar tap ? - Sweep test ? - ROM: WHILE HOLDING THE KNEE - Active: Flexion, Extension, internal and external rotation - Passive: Flexion, Extension, internal and external rotation - Special tests: - Conduct a Lachman test: - Anterior drawer test: - Posterior drawer test: - Stability of the medial and lateral collateral ligaments: - McMurray’s test: internal and external rotation of the feet - Then: - Gait ? - Lower limb neurological exam and vascular exam Neck and back exam: - Inspection: POSTURE: Cervical lordosis, thoracic kyphosis, lumbar lordosis, Scars ? Scoliosis ? Swellings ? Redness ? - Palpation: temperature ? Spinous processes starting from the neck ? Paraspinal muscles ? - ROM è Active= pt, Passive= physician - NECK: Flexion (chin to chest), Extension (look at the ceiling), Lateral flexion (ear to shoulder), Rotation (turn head to each side) - BACK: HANDS ON THE PTS PELVIS TO FIX IT è Flexion (touch toes), Extension ( tilt back as far as you can), lateral flexion (slide your hand down and touch toes), Rotation - Special tests: - Upper and Lower limb neurological and vascular exam, NECK= UL, BACK=LL - Straight leg raising: pt is supine, raise his leg then Doris flex the foot (LOOK AT THE FACIAL EXPRESSION) - Diabetes Mellitus PHYSICAL EXAMINATION: EYE: - Inspect - Pupils ? - Extra-ocular movements ? - Visual acuity ? - Fundoscopic exam? NECK: - Carotid bruit ? HEART AND LUNGS: - Palpate PMI - Percuss chest - Auscultate heart and chest ABDOMEN: - Auscultate - Palpate - Percuss EXTREMITIES: - Inspect: color ? Hair distribution ? Ulcers ? Infection ? - Palpate dorsalis pedis ? - Then start neurological exam NEUROLOGY: - Motor? - Sensation? - Reflexes ? HEENT: Head: Atraumatic, normocephalic. Eyes: EOMI (Extra-ocular movements intact), PERRLA (Pupils Equal, round and reactive to light and accommodation, normal eye fundus. Nose: No nasal congestion. Throat: No tonsillar erythema, exudates, or enlargement. Mouth: Moist mucous membranes, good dentition, no lesions. NECK: Supple, no JVD, no bruit, normal thyroid, no cervical LAD HEART: Regular rate and rhythm (RRR) PMI not displaced ( Point of Maximal Impulse) Normal S1, S2. No murmurs, rubs, or gallops LUNGS: No tenderness to palpation. Tactile fremitus WNL Clear to auscultation bilaterally. No rales, rhonchi, wheezing, or rubs ABDOMEN: Soft, nontender, nondistended, BS++, no hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis, or edema, NORMAL peripheral pulses BILATERALLY Neurological: - Mental status: Alert and oriented × 3 - Cranial nerves: 2–12 grossly intact - Inspection: no deformities, no muscle wasting, no fasciculations - Normal tone throughout - Normal power 5/5 throughout ( all muscle groups bilaterally) DTRs: +2 and symmetric, at the knees, ankles, and planters down gaining bilaterally, – Babinsky bilaterally - Normal sensation using all testing modalities - Coordination intact - Normal GAIT - Negative Romberg Difficult situations while examining: - Female: no breast exam, if you want to auscultate the heart ask her to lift up the bra - In PAIN: I understand that you are in severe pain, and I want to help you. The physical exam that I want to do is very important in helping determine what is causing your pain. I will be as quick and gentle as possible, and once I find the reason for your pain, I should be able to give you something to make you more comfortable Closure: - From the hx and PE, I think most likely you have ONE of these diseases……….. - Pt with DM è Controlled ? Complications of DM ? - But we need to do more exams ( forbidden exams) and Tests ( Blood tests and imaging) to reach a final diagnosis - Counseling è Address bad behaviors (Smoking, alcohol), Address Abnormal vitals - Any FEMALE è DO pregnancy test before IMAGING (CT) è Female on OCPs, came with severe headache è you want to do CT - I will meet you after the tests are done - Thank you - Do you any Qs for me ? è you will face challenging questions
