Patient History

opening

Miss/Mr ___ ? Good morning Mr___

My name is .… I’m the attending physician here today I will take care of
you .nice to meet you (shake)

How would you like me to address you…..

Is there anything I can do to make you comfortable here ?

ok Mr____I will ask you some Qs regarding your health & I will follow it by a
an examination.Then I will share my impression with you. is that ok with you?

may I take some notes while we talk ?

_______________________________

- how can I help you today?

- how did this start?

- do you have the pain all the time or does it come & go?

- (if episodic what is the duration of each episode? when was the last one?

- since this started has it been the same or getting worse ?

- can you please locate the pain with your finger?

-how would you grade your pain from a scale 1-10 where 10 represent the
most sever pain of your life ?

- how would you describe your pain. is it …..?

- does the pain travel anywhere else ?

- does anything make it better ? anything make it worse?

- do you have any other symptoms associated with your pain like N/V ?

Differential dx Qs : now I will ask you some Qs about your general health

- do you have any fever / sweating/ chills / travel hx ?

- do you have any changes in your urinary habits? bowel habits ?

- any rashes recently ? any skin/ hair changes ? eye color changes ?

- any headaches , N/V , vision changes, weakness, numbness ?

- how is your sleep / mood / do you think you are under more stress
recently?

- any changes in your weight recently ? what about your appetite?

- do you exercise regularly ?

Now I will ask you some Qs about you health in the past :

- have you had any similar complaints in the past ? do you have any medical
condition ,like high BP or high blood sugar ? for how long ? any meds
compliant? do you visit your Dr regularly? when was your last visit? what
was the last reading ?

- are you allergic to anything ?

(if yes ) when was the last time you took it ? what happened ?

- are you taking any medications right now ?

- have you had any surgery before ? when?

now I want to ask you about your women’s health : (from Gyne section)

now I will ask you Qs about your family health ?

- anyone with similar problem ?any medical condition runs in your family?

I will ask you Qs about your day to day activity and also about your sexual
health , and let me assure you that everything you gonna tell me will be kept
confidential is that ok ?

- do you smoke?

(No) have you ever smoked ? how many backs/ day you used to smoke? for
how long?

- do you drink alcohol?

(No) have you ever drunk alcohol ? how many glasses/ day you used to drink
?for how long?

C: Have you ever tried to cut down your drinking?

A: Do you feel annoyed when others talk about your drinking?

G: do you feel guilty about your drinking?
E: Do you need a glass of drink as an eye-opener?
- do you use any recreational drugs ? what type ? how much? how often do
you take it ? when was the last time ?

- are you sexually active? can I ask you with whom ?

(if GF)

- how many partners did you have in the last year

- men or women or both ?

- do you use condoms or do you practice safe sex ? if no ask why?

Counsel

- have you been dx with any STDs?

- have you been tested for HIV before? when was it ? what was the result?

Now let me rephrase what you have told me so far

thank you for sharing your problem with me , is there anything else you want
to add

now I would like to start my physical examination , is that ok ?

excuse me I will put my gloves on

how is your day ? study

__________________________

Thank you for your cooperation .

now according to your history and the examination , your problem could be
related to a variety of conditions. it could be…….or ………( explain the d.d. ex
if you suspect cholecystitis say it is an inflammation of your gallbladder and
so on )
right now I’m not sure what is the cause of what you are dealing with so I
need to run some tests including some blood workup like a Complete Blood
Count (CBC) and some imaging studies like X-ray and CT scan ( explain any
tests meaning ) .
Once the results are available, we will meet again to discuss the final dx & the
prober management .
Meanwhile ( depends on the case):

1- (severe pain or ER ) I will keep you under observation and my nurse is

going to give you some pain medications etc.
2- counsel about weight, diet , stress management and so on depending on
the case

Do you have any questions/concerns?

feel free to contact me whenever you have any Qs , it was a pleasure
meeting you, bye( shake)
 ( Patient Notes )

HISTORY

HPI:____ yo M/F c/o _____ for_____ started ____The pain is _____ and ____ on severity.
The pain ↑ with ___and↓ with_______

pt reports ( all the positive)

Pt denies ( all the negatives which misrelated to the system)

ROS: negative except as above

Allergy:NKDA

Medication:HCTZ , atenolol ( compliant )

PMH:HTN x 2 yrs

PSH: cholecystectomy x 20 yrs


SH:CIGGA 1 PPD x 20 yrs. ETOH occasionally or ( 1/4 CAGE) . no illicit drugs use.
sexually active with wife. no hx of STIs

FH:Mother has breast Ca. Father had DM and died of MI

PE

General:A&O x 3, NAD

VS: T 100.2 , or WNL

HEENT: EOMI (extra-ocular movements intact) .PERRLA (pupils were equal, round and
reactive to light and accommodation).no visual field loss. MMM (moist mucus membrane )
wo any visible lesions or pharyngeal erythema . neck was supple. nl thyroid . no LAD.
external ears appeared normal.TM intact

CVS: RRR, S1 S2 audible, no S3, S4, no GRM . PMI not displaced. no JVD, no carotid
bruits

Lungs:CTAB, no RRW, no tenderness on palpation, tactile fremitus WNL

Abd: Soft. NT. ND. tympanic x 4. BS x 4, no organomegaly

Back: no kyphosis midline spine, no CVA tenderness

Ext: no cyanosis, clubbing or edema. . no tenderness . b/l symmetric +2 pulse intact

sensation to LT in all ex .full ROM

CNS: cranial nerves 2-12 intact grossly. 5/5 strength x 4 b/l w/ good tone throughout (or
down-going toes bilaterally). intact ROM . symmetrical and b/l intact sensation to LT.
DTRs: 2+ and symmetric in all Ext (Recruitment utilized for lower extremity DTRs) .intact
finger-to-nose test. intact proprioception. negative Romberg’s . nl gait ( disequilibrium
noted ). Speech was fluent and appropriate.

workup:

1: physical exams which cannot be performed like rectal and pelvic examination, breast 

2: Rule in investigation for DD1

3: Rule in investigation for DD2

4: Baseline investigation (CBC w diff, UA, S/E, BUN, Cr etc.

 ( counseling )

SMOKING

YES: I would be happy to help you to quit; we have many tools to help you. Let's
arrange for an appointment in 2 weeks from now and we can get started from there, is
that OK?”

No: Well I strongly recommend that you quit smoking. Because it is a major cause of
cancer and heart diseases. Are you interested in trying to quit? If yes (see above). If
No If you ever decide to quit smoking, we have a great team of professionals that can
help you with that, whenever you feel ready, I will be here to help you, feel free to
contact me at any time

ALCOHOL

CAGE: if one is yes do counseling as following: “I am concerned about your

drinking, it can lead to liver disease, bleeding problems, heart disease and brain
disease”. If a women in childbearing age: “If you get pregnant, alcohol, can cause
serious problems to the baby like mental retardation.” Are you interested in cutting
down your drinking?

NO: “If you ever decide to cut down your drinking, we have a great team of
professionals that can help you, whenever you feel ready, I will be here to help you, if
you have any questions in this regard, please feel free to contact me at any time”

YES: “I am glad you want to cut down your drinking. We have many tools to help you
to do that, and I will be with you in every step of the process. Let's arrange for an
appointment late this week and we can get started on that, is that OK?.”

PATIENT with many sexual partners but not using protection e.g.condoms

Condoms reduce the risk of sexually transmitted infections, Do you think you could
try to use condoms?

NO: I understand that you may not like to use condoms, but I am concerned that you
may risking yourself for sexual transmitted diseases, you could get HIV, herpes,
chlamydia, gonorrhea, syphilis and any other sexual infections. The complications of
theses diseases include infertility, painful infections .

YES: “I am glad to hear that you use protection that will help you prevent from getting
sexual transmitted diseases.

MEMORY LOSS
- Until we get the test results back, I want to ask your permission to talk to one of your
family members about family and social support and safety at home, Is that OK with
you? We have excellent team of social workers that can help you in manage your daily
activities and future living plans in case you need it

-name ID
- don't go out alone
- don't drive or use stove
- use a diary

DEPRESSION

Mr./Ms.__I believe that you might have depression, it is a common disease due to a
chemical imbalance in the brain.” “I know that dealing with depression can be
extremely difficult. Depression cause physical and emotional stress, but we can deal it,
we have a number of techniques and medications that help with depression.” “Also we
need you do some lab test including: blood cell count, electrolytes that are compounds
that are in the blood and in the cells that help the correct functioning of the body, and
also we need to measure the thyroid hormones, that are substances release by the
thyroid that is a gland located in the neck, this substances help in the correct
functioning of the body; when we get back the results of these test we will discuss the
proper treatment.”. “If we decide to use antidepressants, you should be aware that this
drugs can take up to 4 to 6 weeks to show effects.”

LOSS OF CONSCIOUSNESS

“At this time I must ask you not to drive again or use any other kind of machinery, until
we are sure what caused you to loss consciousness.” “I understand that this is an
inconvenient, but you might hurt yourself or others. I assure you that I will do all I can
to find out the cause of this and find the best way to help you, so you can go back to
your daily activities.”

DIABETES

Are you taking your medications as your doctor prescribed? (compliant?)


YES: I am glad to know that you take your medications as it should, I want to let
you know that beside these medications

there are simple but important measures that gonna help you maintaining your
health, First do regular exercise and follow the diet instructions that my nurse will
provide to you before you leave. Also you should make a habit of using soft
footwear when you walk, because diabetes can lead to injury-induce ulcers on the
foot. You also should regular monitor your blood sugar, so I can adjust the dose of
your medications if needed

NO: I strongly recommend you to take your medications regularly because

diabetes can lead a lot of complications, it may cause vision problems, kidney
disease, nerves damage that can affect your legs, feet and arms and hands; also
can affect the arteries and vessels causing problems in your legs and arms that
may end in amputation. Additionally you will be a higher risk for developing
infections, strokes and heart attacks. If you want I can help you to remember how
to take your medications. Do you have someone who could help you take your
medications? If No We have a social worker who might be able to arrange for a
nurse to come to your home, are you interested in that? Also you should follow
diet instructions that my nurse will give to you before you leave, and do exercise
regularly.

Q:Will I lose my feet, doctor?

Amputation is a last resort in patients with diabetes as a result of

infection . The nerve damage to your feet will not lead to amputation as
long as you protect your feet from injury and as long as you keep your
blood sugar under control

HYPERTENSION

Are you taking your medications as your doctor prescribed? (compliant?)


YES: “I am glad to know that you take your medications as it should. I want you
to know that besides the medications,

there are other simple but important measures that help to control your blood
pressure. First do exercise regularly and modifying your diet will help us to
manage your hypertension, my nurse will give you some diet instructions that you
can follow. Also you should regular monitor your blood pressure everyday, and
write it down, the next time we have an appointment I can look at it and adjust
your medications if necessary.”

NO: “I strongly recommend you to take your medications regularly, because

hypertension is a silent disease that can lead to a lot of complications, it can affect
your heart, your kidneys and your eyes; also it can lead to strokes, heart attacks
and heart failure. I can help you to remember how to take your medications. Do
you have someone who could help you take your medications? If NO We have
a social worker who might be able to arrange for a nurse to come to your home,
are you interested in that? Also you should follow diet instructions that my nurse
will give to you before you leave, and do exercise regularly.

-The palpitations and sweating you have experienced are most likely due to
episodes of low blood sugar, which may have resulted from a higher than normal
dose of insulin or from skipping or delaying meals. The numbness you describe
in your feet is probably related to the effect of diabetes on your nervous system.
Better control of your blood sugar may help improve this problem.

Do you think I have serious problem ?

I understand your concerns but let’s not jump into conclusions . for now

child with DM
it sounds like it has been a tough adjustment for you and your family since your
daughter was diagnosed with diabetes, so your life is going to be a little different
now. We can manage this disease very well through a combination of insulin, a
balanced diet, and regular exercise. I encourage you to attend diabetes classes
with your daughter. Second, everyone in your family, including your daughter,
should learn to recognize signs of low glucose levels, such as confusion,
disorientation, or fainting. Your daughter should always carry a snack or juices
as an "emergency kit. we can also discuss her condition further when you bring
her into the office for an exam.

Challenging Questions to Ask

Your daughter probably developed diabetes due to multiple reasons. She may
have had a genetic tendency to develop diabetes and then certain environmental
factors lead her to get diabetes. Your daughter may have either type 1 or type 2
diabetes. In type 1 diabetes, the immune system attacks the pancreas and destroys
the cells that make insulin. On the other hand, if your child is overweight and is
not physically active, she may have type 2 diabetes, which is a combination of
low insulin and resistance to the action of insulin. In either case, it is not
necessary to have a family history of diabetes. In fact, your daughter can still eat
sweets but in moderation, if you would likeI can arrange a referral to a dietitian to
guide you for healthy meal plans and to learn more about the effect of different
foods on sugar level
 +ve pregnancy test

I will repeat a urine pregnancy test to confirm your home pregnancy test. Your
last period may not have been a real menstrual period, as spotting can frequently
occur in the first trimester.if you are pregnant, I would like to speak with you
about your options with this pregnancy, including carrying the pregnancy to term,
adoption, or termination. After you have some time to think about that,. We will
need to perform a pelvic ultrasound to estimate the dates of the fetus and the
expected date of the delivery. we will check some more blood tests, a Pap smear.
and some vaginal cultures that we routinely perform in every pregnancy.
meanwhile I recommend that you stop drinking alcohol and avoid intense exercise
and excess caffeine. I will be giving you some prenatal multivitamins to take
orally, and we win schedule your future visits.

Q:I’m not married. and didn't plan to have this baby. What should. I do doctor?

I understand your anxiety about this unplanned pregnancy. As your physician, I

want to assure you that I am here to support and advise you in whatever decision
you make.if you wish, I would be happy to discuss your options with you

Q: am I going to die ?

your condition raises concern & is obviously urgent. We will start by taking some
images of your chest. Then, once we have a better idea of what is wrong, we can
give you some medication to help you with your pain. if there is air or blood
around your lungs ,there a procedure we can perform to release the pressure.and
We will be monitoring you very closely

Q: I don't have any insurance. How much will this visit cost?

We have several financial assistance programs that are offered to people
with low income or with no insurance. 

after I finish speaking with you and examining you, I will. have our social
worker come to help you sort out the insurance issues
 Difficulty at home

Your safety is my primary concern, and I am here to help and support you.
Sometimes, living with family members can be stressful for the whole household. Have
you ever considered moving to an assisted living community or to an apartment
complex for seniors?if you are interested, I can arrange a meeting with our social
worker, who can assess your social situation and help you find the resources you need

Crying
stand, hand over the shoulder, tissue or water to the pt

I know it’s a very hard thing to deal with, I’m so sorry about ….., I want to tell you
that I will be here to help you as much as I can and I will listen if you want to talk
about anything
PAEDIATRICS
1-HPI
OCDP ⬆ ⬇ &D.D
3-FEVER CUDDS
4- PAMH
5-BIG DEALS
__________________________________________________

FEVER CUDDS

•Fever:

What do you mean by burning up ? For how long? Continuous or intermittent? High grade or
low grade? What is the reading? Oral or rectal? How high is the fever ?Does he/she have
chills? night sweats?

•Ear pulling & discharge

Does he/she seems to pull his/her ear frequently?

Does _______ have any ear discharge?How is it?

•Vomit:

Has ______ throw up?

color of vomit?

Did you see any blood in it? food in it?

• Eye discharge:

Does he/she have any eye discharge?

•Rash:

Does he/she have any rash?

Does _____ have itching?

Where does he/she have it?

When did the rash start?

Where did the rash start?

Has the rash moved to somewhere else?

•Chest symptoms:

Runny nose/chest pain/ difficult breathing?

Does he/she have cough?

How often does he/she cough?

Does he/she cough up phlegm?

How is the phlegm?

Is there any blood in the phlegm?

•Urinary:

Has _______ increase or decrease the amount of urine?

How many diapers does he/she use?

Has been any change in the color/odor of the urine?

Does _____ have pain when he/she urinates?

•Diarrhea:

Has been any change in his/her bowel habits?

Does ______ have diarrhea?

How many times did he/she have diarrhea?

Have you seen blood in the diarrhea?

Does the diarrhea have mucus on it?

Does he/she have pain or cries during defecation?



•Dehydration:

Does ______ have dry mouth?

How long since his/her last wet diaper?

When ____ cries can you see any tears?

How is his/her energy?

•Seizures:

Does he have any jerk movements?

Has he/she been shaking?

Is any leakage of urine/stools during/after the shaking?

How is his/her level of consciousness?

How is _____ after the seizure?”

***************************************************************************

BIG DEALS
•Birth
history:

Was that pregnancy full term?

Was it a vaginal delivery or a C-section?

Was any complications?

•Immunization:

Is he/she up to date on his/her vaccines?

•Growth and development:

A-Prenata:

Did you have routine checkups during the pregnancy?

Was there any complications during the pregnancy?

Did you take vitamins during the pregnancy?

Did you smoke/drink/use drugs during the pregnancy?

B- Neonatal:

How long did he stay in the hospital after birth?

Did he require oxygen after birth?

Did he need any medication after birth?

Did you start feeding him/her after birth?



C-Infancy:

Is he/she growing well?

Has his/her pediatrician told you that he/she is achieving the milestones for his age?

When did he/she first smile (2mo)/sit up (6-7mo)/start crawling (9mo)/talking (10-12mo)/
walking (1yo)/to dress him/her self/start using short sentences?

How is his/her weight?

•Day care:

Does he/she go to a day care?

Do you know of any other child with the symptoms?

•Eating:

Did you breastfeed him?

Is the formula fortified with iron and vitamin D?

How long did you breastfeed him/her?

When did he/she start to eat solid foods?

How is he/she eating?

Has ______ ever had any problem with any food?

•Appetite:

any change in his/her appetite lately?

•Last checkup & look :

Do you take him/her to the pediatrician?

When was the last routine checkup?

Was everything fine?

•Sleep:

How is _______ sleeping?

Has his/her sleep change lately?

 (Picky Eater)
Differential Diagnosis: AT OHIO

Organic disorder, Habitual Eating Disorder, Iron Deficiency, Oppositional

Defiant disorder, Autism/Adjustment disorder, Thyroid (low)

*How is the child growing? Did he gain any weight? Milestones achieved?

1. For Organic dx:

a. Have you noticed any change in bowel habits?

b. Have you noticed any blood in stools?

c. Have you noticed crying discomfort on passing stools?

2. For Habitual Eating Disorder:

a. Do you follow a set schedule of meals?

b. Does he drink a lot of high-calorie drinks?

3. For Iron Deficiency:

a. Have you noticed a change in skin color?

b. Have you noticed a bleeding from any site?

4. For Oppositional Defiant disorder / Depression:

a. How is his behavior towards others?

5. For Autism:

a. Does the child have problems playing with others?

6. For Hypothyroidism

Have you noticed a change in bowel habits/energy/weight?

7. For Adjustment disorder:

 a. Have you recently moved?

b. Has the child suffered any trauma recently

Workup: CBC with differential, S/E (K+

________________________________________________________________________________________

(FEVER)

Differential Diagnosis: Viral illness, Otitis Media, Meningitis, URI, LRI,

Gastroenteritis, UTI.



1. For Viral illness:

a. Have you noticed any rash on the body?

b. Have you noticed any swelling of the body?

2. For Otitis Media:

a. Does he/she pull the ear?

b. Have you noticed runny nose or redness of eyes?

c. Have you noticed any discharge from the ear? If yes, then ABCO 


3. For Meningitis/Encephalitis:

a. Have you noticed any stiffness in the neck?

b. Did he/she lose consciousness?

c. Have you noticed any shaky movements?

d. Have you noticed bulging of fontanels?

5. For LRI:
*Croup:

i. Have you noticed any a cough?

ii. ii.Have you noticed any sound accompanying? (stridor)

*Epiglottitis:

i. Have you noticed any difficulty swallowing?

ii. Have you noticed drooling of saliva?

*Bronchiolitis : Have you noticed any difficulty breathing?



6. For Gastroenteritis:

a. Have you noticed any change in bowel habits?

b. Have you noticed nausea or vomiting?

c. Have you noticed any distension of the belly?

d. Do you have to use more diapers than usual? 


7. For UTI:

a. Have you noticed any change in urinary habits?

b. Does the baby cry while urinating? 


Workup:

1. CBC with differential, S/E (K+)

2. CXR

3. Blood Culture

4. Lumbar puncture & CSF analysis

 5. Urinalysis

_________________________________________________________________

(Seizures)

Please tell me more about that? Describe the event in


detail? What was the child doing before that?

Have you noticed any LOC? Tongue biting or frothing? Passed urine or stools
without knowledge? What happened after the episode?

Differential Diagnosis: FM TE


Febrile, Meningitis, Trauma/hemorrhage, Hypo/Hypernatremia.

1. For Febrile seizure: (Fever, Family Hx)


a. Do you have a Hx of recent illness?

2.For Meningitis:

a. Have you noticed any stiffness in the neck?

b. Did he/she lose consciousness?

c. Have you noticed any shaky movements?

d. Have you noticed bulging of fontanels? 


3. For Trauma/hemorrhage:

4. For Hypo/Hypernatremia:

a. Have you noticed any change in bowel habits?

b. Have you noticed nausea or vomiting?

c. Have you diluted the formula feed? 


PE: HEENT /CVS Exam.

 Workup:

1. CBC with differential, S/E (K+)

2. CXR

3. Lumbar puncture & CSF analysis

4. CT scan brain

5. Urinalysis

_________________________________________________________________


(Diarrhea)

Differential Diagnosis: Infection, Malabsorption, Intussusception, Overfeeding

1. For Infection:

a. Do you have to use more diapers than usual?

b. Have you noticed any dryness of mouth or tongue?

c. Have you noticed any dryness of skin?

d. Have you noticed sunken eyes?

2. For Malabsorption:

a. Have you noticed any abnormal smell from stools?

3. For Intussception:

a. Have you noticed crying spells or episodes relieved by bending?

4. For Overfeeding:

a. How much and how frequently do you feed the child?

CBC with differential, S/E (K+)/Stool examination

Counseling
Mr./Ms.___, your child has diarrhea, we need to find out the cause of the diarrhea, I
need to see him/her in order to perform a physical exam and some lab tests, so please I
will ask you to bring him/her to my office today, so we can take care of him/her.“In the
meanwhile you can do some measures that will help your son . “First stop giving him/
her cow milk.“Do you know what an oral rehydration solution is? “Give your child as
much of the liquid as he/she requests in small amounts, frequently and continue feeding
him/her the usually food. If he/she vomits wait 10 minutes and give the solution again.

_________________________________________________________________

(Cough)
Differential Diagnosis: LPC FERA.

Laryngitis, Pertussis, Croup, Foreign Body, Epiglottitis, Retropharyngeal

Abscess, Asthma

1. For Laryngitis: Have you noticed any change in the voice?

2. For Pertussis:

a. Have you noticed a runny nose or watering from eyes before a cough
appeared?

b. Have you noticed any additional sound along with the cough?

c. Did the baby throw up?

3. For Croup:

a. Have you noticed any cough?

b. Have you noticed any sound accompanying? (stridor)

4. For Foreign Body:

What was he doing when a cough started?

5. For Epiglottitis:

a. Have you noticed any difficulty swallowing?

 b. Have you noticed drooling of saliva?

6. For Retropharyngeal Abscess: (High-grade fever + No stridor)

Have you noticed any drooling of the saliva?

7. For Asthma:

a. Does the baby have any allergies?

b. Have you noticed any relationship to the timings of the day? 


PE: HEENT /CVS / Pulmonary

workup

1. CBC with differential, S/E (K+)

2. X-Ray neck

3. CXR

4. Blood Culture 


PEDIATRIC PATIENT WITH ENURESIS

Mrs. Smith, bed wetting is extremely common at this age. Studies show that with each
advancing year about 10% of kids with bed wetting will outgrow their symptoms. A
number of behavioral modifications can help decrease bed wetting. These include not
drinking liquids in the last couple hours prior to going to bed, waking the child up in
the middle of the night to urinate, avoiding tea/coffee or caffeine containing soda with
dinner and ensuring that 'Tommy' goes to the bathroom just before going to bed. If
these modifications don't work we may consider bed wetting alarms or even
medications in the future.
GENERAL
 (Anxiety)

-Ask if nervous or anxious

1-psychiatry
Panic Disorder:

a. Is there any particular event associated with the racing of heart?

b. Does your breathing rate increase during the episode? Do you feel
dizzy during the episode? racing in your heart?

GAD:Do you feel worried about something in particular or generally about

everything?

Acute stress: (<1 months)

a. Have you experienced nightmares recently?

b. Have you experienced flashbacks?

PTSD: (>1 month)

a. Have you experienced nightmares recently?

b. Have you experienced flashbacks?

2- Caffeine

Do you consume caffeinated beverages? If yes, then ask how much?

3- Substance Abuse 


4- Hyperthyroidism

Temp intolerance/Bowel movement/Have you noticed racing of heart/Have you

noticed any skin changes/Have you noticed any tremors of hands?
 5-Menopause

PE:

HEENT -CVS -Pulmonary exam

Workup:

1. CBC with differential, S/E

2. TSH, T3 & T4.

3. Urine toxicology screen

4. if +ve palpitation EKG

5. If menopause FSH/LH



____________________________________________________________

(Night sweats)

1-Endocrine:

Hyperthyroidism

Hypoglycemia ( skipped meals/ change of drugs or doses)

2-Cancer: weight/appetite loss

Lymphoma: Belly distention/fullness/swellings

Carcinoid: episodic flushing, racing/ diarrhea/ wheezes

Pheochromocytoma: episodic headache/racing/sweating/tremors

3-Infection:

TB : PPD, travel, living conditions, ill contact

 night sweat, cough Bloody sputum, weight loss

HIV: swelling anywhere, IV drug abuser, sore throat, weight loss, Diarrhea

IM: tired more than usual/ belly pain/sore throat/ sexual hx 


4- Gyneacology :

Premature Ovarian Failure, Menopause Qs

PE: HEENT /Chest/GI

Workup:

1. Rectal and Pelvic Exam

2. CXR and Sputum analysis

3. Western blot for HIV

4. T3, T4, TSH

5. Blood Sugar Level

6. FSH, LH

Closure
Mr./Ms. XYZ thank you for your patience and cooperation. Depending on the history
and PE, I am considering a number of possibilities of your current complaint that it
might be due to ______________, but I am not sure right now. For this, I will have to
run some tests that will include some blood work up like complete blood count, sputum
examination, and some imaging studies like X-ray and CT scan of your chest. When the
results are available, we will sit together and discuss the further management plan and
you don’t need to worry since you are in safe hands. Meanwhile, I am KUO and
provide adequate hydration and will advise you to always wear a mask, try avoiding
contact with people who have infections and get yourself vaccinated. Exercise
regularly, follow a healthy lifestyle and keep stress at a minimum

______________________________________________________________________
 (Fatigue)

1-Endocrine:

-DM

a. Do you feel more thirsty than usual?

b. Do you have to urinate more frequently than usual?

-Hypothyroidism

-Sheehan’s Syndrome

a. any excessive bleeding?

c. Were you able to lose your weight after delivery?

d. Have you been able to breastfeed your child?

2-Infections:

-TB, HIV, IM

3-Malignancy

4-Psychiatry:

-Depression (SIGECAPS)

-Adjustment / PTSD

5-Other:

-Anemia

a. Have you noticed any change of skin color?

 b. Have you noticed SOB on exertion?

c. Have you noticed excessive bleeding from any site of the body?

- Apnea

a. Do you snore at night? Or has someone told you?

b. Do you feel restless at night? Or has someone told you?

- Myasthenia

a. How does it progress during the day?

b. Have you noticed weakness of muscles or double vision? 


PE:

HEENT / Thyroid Exam 


Workup:

1. CBC with differential.

2. TSH, T3, and T4.

3. Monospot

4. ELISA

5. CXR

6. BSL

7. Acetylcholine receptor antibody.

8. CT scan Brain.

9. MRI Brain. 

___________________________________________________________
 (DELIVERY BAD NEWS)
S-P-I-K-E-S

Setup:

◦ Enter the room, look the patient in the eye and do your standard introduction

◦ “I have scheduled a full 15 minutes and asked my nurse not interrupt us”

Patient perception

◦ “Do you remember why we did this test?”

◦ “what did you think the (symptom) was from?”

Invitation

◦ “I have the results back. Would you like to go over them now?”

◦ “Would you like the basic information or all the details?”

◦ “So if turns out to be something serious you would like to know?”

Knowledge

Mr./Ms.______, I am sorry to have to tell you that the pathology report shows that
what you have is serious and will require treatment.”

◦ The biopsy showed a tumor or The test shows that you have: ______

Emotions:

this is a good time to use the appropriate touch in the shoulder or forearm and offer the
patient a tissue or sip of water, or just sit quietly for a few seconds.

◦ I can see you are upset. I was also upset when I got the results.
◦ I know what you have is serious but we first have to do some additional test to find
out exactly how advance it is. Either way, we do have treatment options and
we are going to be very aggressive. I will help you through this entire process.

◦ have ______ to help you dealing with this? If you would like, at your next visit I can
talk to your family or anyone else who will be helping you.

◦ we also have counselors and support group of other people going through the same
thing

Summarize

◦ Mr./Ms. ________ I know I gave you a lot of information to remember today. I want
to make sure you understand me correctly.”

◦ Do you have any questions

◦ My nurse is going to give you my contact information, please feel free to call me
if you have any questions before your next visit. I will get all the test scheduled
today with my nurse. I would like to see you next week, and we will go over all
of the results. Is that right with you?

______________________________________________________________________

(FOLLOW UP CASES)

Dr : How can I help you today?


Doctor these are my medications please fill them for me!

Dr: Oh, surely I will give you the refills and I know these are very important for
you. But Mr as this is our first encounter and I don't have access to your previous
medical records so let me ask a few questions so that I can have a better idea what
is going on with you. Is that ok? So do you have any active complaint at the
moment?

If the patient says yes, then go to OCD & General Qs .

If the patient says that he has no active complaint, then say: I’m glad to know
that! May I ask for which reason you were using this medication? OR you can say
that my nurse told me that your blood pressure is on the higher side so I am
concerned if your blood pressure/diabetes is controlled with these medications or
not. That’s why I will need to ask a series of questions so that I can get a better
idea of whether to change or add the new medications. Is that alright, Mr. I'll be
very quick
General Qs:

Diagnosis: When were you diagnosed? what symptoms you got at that time?

Medication: What medications do you take? How often do you take it? Side
effects: Do you have any side effect from the drug that you take?

Monitoring: How often do you check your blood pressure/blood sugar? when
was the last time?

Checkup: When was your last checkup with your doctor?

Compliance: How do you take your medication?

Current status: How do you feel now? do you have another concerns for today?

Complications (e.g.DM, HTN.etc) or other symptoms

Concerns and questions (refills)

A-HTN
B- DM Cases

DIABETIC Qs :

- Diet & decrease glc level (skipped meals & hypoglycemia symptoms)
- infection :Have you had any infection lately? UTI symptoms ?
- A1c hemoglobin
- Blurry vision: Have you noticed any change in your vision lately? When was
your last eye checkup?
- Extremities: Do you have any injury in any of your limbs? When did it
happen? How is now?

- Tingling: Do you feel numbness/weakness/tingling in your legs?

- Impotence: (Have you noticed any change in your sexual Performance )
1 -Psychological causes:

How is the relationship with your spouse?

Do you have morning erections?

(Stress/Sad + SIGECAPS)

2-Vascular causes:

Have you noticed any pain in your legs?

Have you noticed any Weakness of your body?

Have you noticed any Numbness or Tingling of your body?

3-Medications : (are you taking any drugs?


4-Hypogonadism:

Have you noticed any change in your sexual Desire?

Do you have normal pubic and axillary hair?
 -CVS : HTN, claudication ,Past Hx of MI, SOB, racing of heart, Chest pain


PE:

HEENT ( Fundoscopy) /CVS Exam



workup:

1.CBC with differential.

2.CXR

3.BSL and HBA1c

4.Urine for Microalbuminuria , Urinalysis

————————————————————————————————


(DOMESTIC VIOLENCE)

SAFE GARDS:

Safe: Do you feel safe at home?


Alcohol:Does your husband drink alcohol?

Does your spouse use any recreational drug?How often does he/she use it?

Family/friends: is there anyone in your family or friends know about this
situation?

Emergency: Do you have an emergency plan?

Guns: Is there any gun at home?


Abuse: Are your kids abused too? Have you been abused?

Relationship: “How is your relationship with your husband/wife? Do you feel
threatened by him/her?

Depression: Are you feeling sad/down/low energy? Interest? Have you lost
weight? how is your appetite?

Suicide: have you ever thought about ending your life?Do yo have a plan?Could
you please tell me?

If Assault +ve:
1) Can you describe what happened to you?
2) What did they use to hit you?
3) Where did they hit you?
4) Do you have any pain? Where?

-From what you have told me I understand that at times you feel unsafe at your
own home. That sounds very frustrating. I am glad that you came to seek
attention. If you ever need someone to talk to, do not hesitate to call our office. If
ever you feel unsafe or are hurt you should seek attention from the police or
appropriate authorities. Feel free to contact us at any time, we are here to help
you
-I am really sorry for what happened to you. I want to emphasize that it is not your
fault, and you should not feel guilty about it. I recommend that you report the incident
to the police. In the meantime, I will need to do a pelvic examination to make sure you
have no injuries in the genital area. In addition. 1 will need to take a swabs from your
body and genital area so that they can be used as evidence if you choose to file charges,
and also to look for sexually transmitted infections. we will order a pregnancy test . x-
rays to look for other injuries. We will also give you some antibiotics to protect you
from infections. Finally. I can have our social worker come talk to you and provide you
with resources that will help you process this trauma moving forward. Do you have any
questions for me?

-I am so sorry for what happened to you. It is horrific and must be very difficult to
handle right now. however, its not your fault by any means. right now, I want to
make sure you arc in a safe environment and medically stable. There are a number
of resources available to help you process this event

———————————————————————————————————
 (Sleep problems)

a-Do you have any problems falling asleep? any problems staying asleep?What
time do you wake up in the morning? How many hourdo you sleep a day?
b- Bad sleep hygiene:

What do you do before you go to bed?

Do you take naps during the days?

Differential Diagnosis:

Brain: Stress, Circadian Rhythm , psych

Mouth: Drugs, Caffeine

Neck: Hyperthyroidism, OSA

(1)caffeinated : a. Do you consume caffeinated beverages? how much?

b. Do you take tea/Coffee/energy drinks before going to bed? 


(2) illicit drugs use ?

(3) Circadian rhythm : Have you traveled for a long distance recently? Have you
changed your work hours (shift) recently?
(4) psych: Depression/GAD/PTSD/stress
(5) OSA:Do you feel sleepy during the day?Do you snore at night? Or has
someone told you?
Do you feel restless at night? Or has someone told you?
(6) thyroid
PE: MMSE & HEENT
Workup:
 1. CBC with differential, S/E

2. TSH, T3 & T4

3. Urine Toxicology screen.

4. sleep study

counseling :

*sleep hygiene *alcohol can worse it

I would advise you to avoid caffeinated beverages 3-4 hours before going to bed,
go to your bed only to sleep, make sure your room is dark and curtains are drawn
down, and avoid watching television or reading before going to bed. Eat a healthy
and balanced diet high in fruits and vegetables, low in salt, and caffeinated
beverages. Do regular exercise, follow a healthy lifestyle, and keep stress at a
minimum.

Trauma

any pain anywhere ? what happened ?

Trauma with chest pain:

pneumothorax

hemothorax

fracture rib

muscle sprain

Gynecological Cases
A-Period :
Ok Ms. XYZ now I would like to ask you a few Qs about your gynecological health,
is that ok with you?

1) When did you have your first menstrual period?

2) When was your LMP?

3) Are your periods regular ?

4) How often do you get your menstrual period? 5) How long does it last?

5) How many pads do you use in a usual day?

—————————————————————-

1) Do you have cramps with your periods?


2) Do you have any difficulty with intercourse?

3)Is there any vaginal discharge? What is the color? Does it have any specific odor?

4) any vaginal bleeding?

5) any vaginal itching?

6) Have you been getting regular pap smears? When did you have the last pap
smear? what was the result?

B-Pregnancy:

1) Have you ever been pregnant? How many times?


How many children do you have?

2) Have you ever had a miscarriage or an abortion? How many times? In which
week of your pregnancy?

3) Are you pregnant now? Have you had a pregnancy test recently?

C-Breast:
(1) Do you have any breast/nipple discharge? (2) Do you have any swelling in your breast? 


Vaginal bleeding

(1) Is it bright red or there are clots?


(2) Is it heavier that your usual menstruation?

(3) How many pads did you use per day?

(4) Is it related to intercourse?

(5) Have you noticed any vaginal bleeding between your periods?

Vaginal discharge

(1) Since when have you noticed it first

(2) Can you tell me what is the amount?

(3) What is the color?

(4) any blood on it 


(5) Has it any bad odor?

Hot flashes

(1) Since when did you start having them?


(2) How often do you have them?

(3) How long do they last?

(4) Is there anything that (increase/decrease) them?

(5) Do you think they are increasing or decreasing in frequency?
(6)Have you noticed sweating/palpitations with flashes?

Menopause

Do you have hot flashes?


(2) Do you have difficulty with intercourse? vaginal itchy? dryness?

(3) Do you have back/bone pain?

(4) Have you noticed any change in your mood?

(5) Do you have any problems controlling your bladder

(1st & 3rd Trimester bleeding)

A: amount (how many pads/day)

B: pain

C: clots? contractions?

D: dizziness

E: evaluation ( when was your last checkup visit? any abnormalities

F: fever ( ectopic, endometritis) / fetal movement changes/ fluid?

RheumatologyCases
A-OCDP LIQRAAA

B-JOINTS

1) Do you have pain in your joint? Other joints?

3) Have you noticed any swelling in your joint?

4) Have you noticed any redness in your joint?

5) Do you feel your joint is warm?

6) any stiffness

C-Overuse & Trauma

any recent heavy lifting /any recent injury

BURN

1-weakness (can you move it or can you walk)/tingling/ numbness

2-incontinence/ erection

3-claudication pain

4-N/V

Rash/Mouth ulcer/Photophobia/ Eye changes/Hair/Skin

********************************************************************

Neck pain meningitis (neck stiffness/ill contact)

shoulder pain angina Qs

Back pain all neuro Qs
Hip pain back Qs
leg & calf pain V.V/DVT as recent immobilization or surgery/cellulitis
knee & heel pain
-SLE qs from R
-Reactive arthritis:
-Lyme dx : tick bite
-with Heel if improve with rest; fracture/strain but if improve with movement;
planter fasciitis
Main D.D of Knee pain :

1-OA 2-RA 3-PFS 4-MENISCAL TEAR

———————————
thank you for your cooperation . now depending on your history and physical
examination, your problem could be related to a variety of condition. it could
be a wear & tear in your knee or a more serious infection in your knees .But
till now I’m not sure what is the cause of what you are dealing with .so I need
to run some tests including some blood work up like a Complete Blood Count
(CBC) and some imaging studies like X-ray and CT scan. once the results are
available, we will meet again to discuss the final dx & the prober management
. Meanwhile,I will keep you under observation and my nurse is going to give
you some pain medications etc.
or meanwhile ( counsel)
Do you have any questions/concerns for me? Yes/ No.
feel free to contact me whenever you have any Qs , it was a pleasure
meeting you, bye( shaking)

shoulder pain
.

you may have a fractured bone, a simple sprain, or a dislocation of the

shoulder joint. We will need to obtain an image of your arm to make a
diagnosis, and MRI may be necessary as well. Your safety is my primary
concern, and I am here to help and support you.

Q:Doctor, do you think I will be able to move my arm again like before ?

Hopefully your range of motion with your arm will go back to normal, but
first we need to out exactly what is causing your problem

 calf pain
. My father had a clot in his leg. What do you think I should do to make sure
I don't get one to?

There are several measures you can take that may prevent you from having
a clot.you should avoid immobilization for long periods of time for
example, while sitting at your computer desk or on

plane trips.try to move in place or take a short walk. if you are on oral
contraceptive pills, I strongly recommend that you stop taking them, as
they are known to precipitate clotting.I also suggest that you exercise
regularly and manage your diet." 


it is possible. that you had a blood clot. However, we will also look for other possible
causes of your symptoms, such as an infection or a ruptured cyst.
Gastrointestinal Cases
A-General

-Do you have difficulty swallowing?

-Do you feel nauseated?

-Do you vomit (throw up)? How many times? How much was it? Was there
any blood in it? What color was the vomit?

-Do you have heartburn?

-Do you have abdominal pain?

-Do you have diarrhea? constipation?

-Have you noticed any change in the color of your stool?

-Was there any blood or mucus in it?

B-Bowl movements

Is it painful when you have a bowel movement?

Do you feel that despite the urge to defecate you can’t start that? (tenesmus)
Do you feel you’ll not make it on time to the rest room? (urgency)
Do you feel you can’t completely empty your bowel?

C-Contamination
Did you eat any food that may be contaminated?

Do you have any contact with ill persons?

Neurological Cases
A-Head
(1) Do you have headache?

(2) Do you feel dizzy? Tell me exactly what you mean by dizziness? Did you
feel the room spinning around you or did you feel light headed as if you
were going to pass out
(3) Have you ever lost consciousness
(4)Have you had any convulsions
(5)Do you have any difficulty with concentration
(6)Have you been recently forgetting things more than before?

B-Limbs
(1) Do you feel weakness in your limbs? numbness?
(2) Do you have any difficulty while walking?
(3) Do you have tremor?

C-Sense
(1) Do you have difficulty swallowing?Speech difficulty?
(2) Do you have any visual problems?
(3) Do you have any hearing problems? Do you hear any ringing in the ears?

D- Head Trauma
E- Ill contact
F- URTI

MMSE
What’s today? What time is it? Where are we now Who am I?
Now I’ll say 3 words can you please repeat them after me? Hat-Rat-Cat
 Now keep them in mind I’ll ask you about them later.
Ok, now one hundred minus seven is? Ninety three minus seven is?
Ok, what where the words that I told you?

Dementia
(1) Do you have any difficulty with concentration?
(2) Have you been recently forgetting things more than before?
(3) Do you have any problems with doing daily life activities like dressing,
bathing, eating? Do you need any help dressing?
(4) Can you do shopping by yourself? Paying bills? Housekeeping?
(5) Is there anything to help you when you need?
(6) Do you have any problems controlling your bladder?

(7) Have you ever lost your way back home?

Parkinson
(1) Do you have hand tremor
(2) Do you have difficulty in starting any movement
(3) Do you have frequent falls
(4) Do you feel your body is stiff?

(Dizziness & LOC)

if Dizziness:

1-what do you mean by dizziness, do you mean you feel the room spinning
around you or do you feel you are going to pass out ?
2-did you passed out?

3- related to position ?

Then:

A-Ear : balance problems ( do you have any problems maintaining your balance)

if +ve :pain/discharge/hearing loss/ringing /URTI

if LOC: for how long?

Did you sense anything unusual before passing out? N/V/sweating

Did anyone notice jerky movements? (Shaking)

Did you bite your Tongue while shaking?

Did you pass urine without your knowledge?

Were you confused after you regained consciousness?

Differential Diagnosis:

CVS: Cardiac arrhythmia, Aortic Stenosis, Orthostatic Hypotension,

vasovagal syncope

CNS:, Mass, Seizure syncope

Other: Panic attack(fear), Hypoglycemia(sugar), Alcohol Withdrawal(drug)

*Hypoglycemia:

Do you have a Hx of High blood sugar level?


Have you skipped meals? Or changed any dose or medications recently?
 *Alcoholic withdrawal: (Ask about alcohol use) When was your last
drink?

*Dehydration:

Have you noticed any changes in bowel habits? How many pads do you use
on a heavy day?

*Cardiac Causes:

Have you noticed any chest pain? SOB? Racing of heart? Skipped beats?
Sweating?

*Mass:

Have you noticed any Weakness Numbness Tingling or Headache ?

*Vasovagal Syncope: (Nausea, vomiting)

PE:

MMSE – Orientation Only (AAO) /CVS (auscultation , carotid ,pulse) /CNS Exam

Workup:

1. CBC with differential + S/E.

2. EKG, ECHO, orthostatic vital signs, heart monitor

3. BSL

4. CT scan Brain.

5. MRI Brain. 


Closure

Meanwhile, I am KUO and my nurse is going to give you some fluids so that you don’t
feel dizzy anymore. Meanwhile, I would advise you that you should not go out
unaccompanied, keep an I.D. with you always, and don’t drive until labs are available.

(In case of hypoglycemia) Keep a candy or granola bar with you and eat them
whenever you feel dizzy. You should be careful when you stand up or walk. Use hand
railings whenever possible.
_______________________________________________________________________________

Seizures
Same Qs of LOC (before/during/after)

Differential Diagnosis:

1-CNS: Infections (Meningitis, Encephalitis, Abscess), Trauma, Tumer ,Drug

Abuse/Withdrawal(Alcohol, Benzodiazepine),stroke

2- metabolic : hypoglycemia, hyponatremia ( diarrhea, more thirsty)

3-Autoimmune:SLE: Have you noticed any rash or joint pain?

PE: MMSE – Orientation Only (AAO) /CNS Exam

Workup:

1. CBC with differential, S/E (K+)

2. Urine Toxicology screen

3. Blood Culture

4. Lumbar puncture & CSF analysis 


Closure

Meanwhile, I am KUO and my nurse is going to give you some fluids so that you
don’t feel dizzy anymore and a new pair of pants as well. Meanwhile, I would
advise you that you should not go out unaccompanied, keep an I.D. with you
always, and don’t drive until labs are available. You should be careful when you
stand up or walk. Use hand railings whenever possible.
URINARY SYSTEM
 bladder ca or urolithiasis

I will perform a genital exam as well as a rectal exam to assess your prostate. I will
then order a urine test to look for signs o f infection. Depending on the results we
obtain, I may also order some imaging studies to determine if there is a stone in your
kidneys, an anatomic abnormality

Challenging Questions to Ask


They told me that having blood in my urine is because of my old age. Is that true? No.
Bloody urine is rarely normal. We will need to run a few more testa t o determine
the cause of this finding."

spinal stenosis or metastatic ca

Do you think I can go to work, doctor, Can you write a letter to my boas so that I
can have some time off?

"You're right; heavy construction work can worsen your back pain or cause it t o heal
more slowly. To assess the need

for you to take a time off, I would like ask you some questions and perform a
physical exam

I would like to do a rectal exam and assess your prostate. I will also run some
blood tests and order an x-yay and possibly an MRI of your back so that I can
better determine the cause of your pain, which could be a pinched nerve or
muscle spasm. In the meantime, I will write a note to your employer requesting
that you be given only light duties while you are at work
Cardiovascular and Pulmonary
(1) Have you ever felt dizzy or light headedness?

(2) Do you feel tired?
(3) Do you feel short of breath?

(4) Do you have chest pain?

(5) Do you feel your heart is racing rapidly? Beating fast?
(6) Have you noticed any leg swelling?

________________________________________
(1) Do you have runny nose? sore throat?

(2) Do you feel SOB?


(3) Do you have chest pain?

(4) Have you been wheezing?
(5) Do you have sore throat?

(6) any cough?

(7) Is there any sputum (phlegm) with your cough?
How much is it? Tea spoon? Table spoon? Cupful? What color is it? Is
there any blood in it? Does it have any special smell?

Heart attack

the source of your pain can be a cardiac problem such as a heart attack. or it
may be due to acid reflux, lung problems, or disorders related to the large blood
vessels in your chest it is crucial that we perform some tests to identify the source
of your problem. We will start with an ECG and some blood work.
Is a heart attack? Am I going to die?

"Your chest pain is of significant concern. However, chest pain can be caused by
a large variety of issues. We need to learn more about what's going on to know if
your pain is life threatening."
 (Sore Throat)
Differential Diagnosis: PNIG

1. Pharyngitis:

a. Have you noticed any pain or fullness in the ear?

b. Have you noticed any redness or discharge from eyes?

* Gonococcal pharyngitis with sex hx

2. Infection:

a.HIV: (IV drug abuse , tattoos , Fatigue, Sexual behavior, swellings,

occupation )

b.IM:

Have you ever been exposed to anybody with similar complaints? Do you
feel more tired than usual? Have you noticed any fullness or pain in the
belly?

3. For GERD: 

Have you noticed any burning sensation in your chest? Or change in taste
of your mouth?

5. Post Nasal Drip: Have you noticed recurrent cough?



PE:

1. HEENT

2. inspect, palpate, (Sinus Tenderness)

3. CVS and Pulmonary exam

4. Abdominal Exam (for Splenomegaly)

Workup:
1. CBC with differential, S/E

2. ESR

3. Rapid Strep Test

4. Monospot Test

5. ELISA

6. Western Blot

7. Endoscopy