CASES

1. Normal- RS /CVS /GI-GU /CNS /HEENT

2. Psychiatry Depression, Insomnia, Psychosis hallucinations
3. Dementia - Confusion
4. Abuse
5. Pedia
6. Enuresis
7. Tantrum
8. Picky Eater
9. Follow up DM, HTN & Drug refill
10. Insurance
11. Bad news
12. Terminal stage






No one can get the Pearl without touching the Sea shore.

Best Wishes,
Dr. Dharmesh Mehta
Knock the door thrice,
Smiling patient not in distress - GIVE SMILE Not smiing- in distress NO SMILE, NEVER SIT
Good Morning Mr. / Miss._________ I am Dr. Mehta. I will be your physician today. Today I will
ask you some questions and perform a physical exam. Is that ok?
Are you comfortable in this room? Let me make you more comfortable by draping you. (If says
no- Is there anything bothering you?) (Drape the patient) (While draping )
During our conversation if you have any concern then please let me know. Hope you dont
mind if I make some notes while asking you questions.
Chief complain -
So, Mr. _____________ How can I help you?
Oh! I am sorry to hear that. Can you tell me more about it? ..I will try my best to help you.
History of present illness - O-P-D
General-
When did it start? (When did you first notice it?) - O
Do you know anything which may be responsible for your ? (Do you remember anything
which might have brought it?) -D
So as you told me that you have.. Then has it been remaining same or getting worse? - P
Is it continuous or comes and goes? (if intermittent- How often does it occur? How long does it
last for?) - P
What does make it better?
What does make it worse?
Do you have any other complains besides .?
(CVS/RS Cough, Breathlessness, Chest pain, CVS Palpitation, Sweating)
(ABD-Pain in abdomen, Bowel- bladder, Jaundice)
(CNS Headache, Dizziness, Seizures, Sensations, Weakness, Difficulty - vision, hearing, speech,
walking, Loss of consciousness)

PAIN- (Chest, Abdominal, Headache, Joint pain)
- When did it start?
-So as you told me that you have.. Then is it remaining same or getting worse?
-Is it continuous or comes and goes? (if intermittent- How often does it occur? How long does it
last for?)
Location - Can you show me the exact site with your finger? (except vagina/penis, anus, back
where do you feel it? )
Intensity How would you grade your pain on a scale of 1 -10, if the 10 is the worst pain of your
life?
Quality - How does it feel like? (I mean sharp, dull, throbbing, burning)
Radiate Does it move anywhere?
Alleviating factors what does make your pain better?
Aggravating factors what does make your pain worst?



GENERAL - Do you have any fever, nausea, vomiting? ASK IN EVERY PT.

a. Fever
i. Do you have any fever?
ii. Is it continuous or it comes and goes? (if intermittent -How often does it occur? How long
does it last for?)
iii. Is there any chills? Any night sweats?
iv. Have you measure your temperature
b. Nausea
- Do you feel nauseated?
c. Vomiting - C-B-C
i. Did you vomit?
ii. What was its color?
iii. Was there any blood in it? (If Yes - How much?)
iv. Can you estimate the amount of it? (Cup full)
(A.) RS + CVS
Do you have any cough? Short of breath? Chest pain? Racing of your heart?
a. Cough
i. Do you have cough?
ii. Sputum- Do you bring up anything with it? C-B-C
iii. Color - What is its color?
iv. Blood Is there any blood in it? (If Yes - How much?)
v. Quantity - Can you estimate amount of it?
Vi. Smell Is it foul smelling?
b. Breathlessness
i. Do you have short of breath?
ii. Relation with exertion - When do you get SOB? [walking, climbing upstairs]?
How far can you walk on ground level before you have SOB?
How many steps can you climb before you have short of breath?
iii. PND - Do you have attacks at night?
- What do you do to relieve your attacks?
c. Chest pain- Do you have chest pain?
L I Q O R A A A=
d. Palpitation Do you have racing of your heart? General + thyroid
Sore throat
Do you have any Running nose? Ear discharge? Difficulty in swallowing? any Swollen glands in
neck? Rash?
(B.) ABDOMEN
Do you have pain in your belly?
Do you have any problem with your urination? Bowel movement? Sleep?
Have you notice any change in color of your skin? Your eyes?
a.Abdominal pain
Do you have pain in your belly?
L I Q O R A A A
- Is there any relationship with food? or Do you know anything.?
b.Jaundice
Have you notice any change in color of your skin? Your eyes?
Do you have any itching? Any joint pain?
Have you ever received any blood transfusion? Immunization for jaundice?
(bowel color of stool, Bladder color of urine, sexual, alcohol, travel)




(C.)CNS
Do you have any Headache? Dizziness? Jerking movements?
Do you have any Numbness? Weakness?
Do you have any problem with your Vision? Hearing? Speaking? Walking?
Have you ever passed out?

a. Headache
I. Do you have headache?
ii. L I Q O R A A A
iii. Aura - Can you tell me what happens before your headache?.
1. Any Watering of your eyes? Any Running nose?
2. Any Unusual lights, sounds, smells?
iv. Neck stiffness - Have you notice any stiffness in your neck?
b. Dizziness
1. Do you feel dizzy?
4. Is it continuous or comes and goes? (if intermittent- How often does it occur? How long does
it last for?)
5. Is there any relation with position? - BPPV
6. Do you feel that the room is spinning around you or you are moving inside the room?
8. Do you hear ringing of bell in your ears? - Tinnitus
9. Do you have any ear discharge? Ear pain?


c. Seizures
-Do you have any jerking movement?
- How often does it occur? How long does it last for?
- (When did it occur last time?) What did happen at that time? Did you pass out? Fell down?
- Can you tell me what happened before the attacks?
-Racing of your heart? Dizziness? Unusual lights, sounds, smells?
- Can you tell me what happened during the attack?
-jerking movement? can you describe it? Tongue bite? Frothing from mouth? Loss of
control of urination or bowel movement?
- Can you tell me what happened after the attacks?
-numbness, weakness, headache, confusion?

d. Loss of conciousness-
- Have you ever passed out?
- How often does it occur? How long does it last for?
- (When did it occur last time?) What did happen at that time?
e. Difficulty in hearing-
- On which side of ear, you have problem with hearing?
- When did you notice it?
- Do you hear ringing of bell in your ears? - Tinnitus
- Do you have any ear discharge? Ear pain?
- Have you ever exposed to loud sound?

(D.) Joint pain T-R-I-R
i. Do you have any joint pain?
ii. L I Q O R A A A
iii. Trauma Do you have any injury recently? (if yes - Do you have any weakness around
your joints?) (Nerve injury)
iv. Stiffness/Swelling/Redness Have you noticed any redness/swelling/stiffness in your
joints? When does it occur? How long does it last for? (RA/OA/AS)
v. Insect bite Have you noticed any insect bite recently? (Lymes)
(Travel Have you traveled recently?)
vi. Rash - Have you noticed any rash in your body? (When did you notice it? Where did it
first start? How did it progress? Can you describe your rash?
pain/ burning, itching, discharge- color , foul smelling)
vii. Mouth ulcers Is there any ulcer in your mouth?

Vii. Do you have similar complain/ Pains in other joints?










P-A-M H-U-G-S F-O-S T-A-R-A-W
Well, Mr. _____ Now I am going to ask some questions about your past medical health. Is that
ok?
1. Past History Have you ever had similar complain in the past? if yes- Can you tell me more
about it.
Do you have Diabetes, high blood pressure, high cholesterol? Any other illness?
A. Diabetes?
i. When was it detected?
ii. Do you get your blood sugar checked regularly? What was the last reading?
Iii. Are you taking any medication for it? (No) Can you tell me why it is so?
iv. Which medication are you taking? (No) Do you have any prescription for that right now?
v. Do you take it regularly?
[Vi. Do you have any side effects like ? Sweating, racing of heart?, black out - hypoglycemia
Fundoscopy- if follow up]
Mr._____ As a concerned physician, I must inform you that high blood sugar may damage your
heart and blood vessels.
So I recommend you to get your Blood Sugar checked periodically and take your treatment
regularly. You should also consider for low sugar diet.
So I STRONGLY recommend you for regular follow up and treatment.
I am glad to hear that you are taking good care of your blood sugar and I hope that you will
continue it in future.
I am glad to hear that you are taking your treatment regularly, but you should also get ..
I am glad to hear that you are getting your blood sugar checked regularly, but you should also..

B. High Blood Pressure?
i. When was it detected?
ii. Do you get your blood pressure checked regularly? What was the last reading?
Iii. Are you taking any medication for it? (No) Can you tell me why it is so?
iv. Which medication are you taking? (No) Do you have any prescription for that right now?
v. Do you take it regularly?
[vi. Do you have any side effects like..?
CCB- headache, constipation, B blocker- depression, impotence, ACE- cough, Diuretics
ototox- hearing loss, tinnitus
Fundoscopy if follow up]
Hypertension
Mr._____ As a concerned physician, I must inform you that high blood pressure may damage
your heart, blood vessels and many other organs.
So I recommend you to get your Blood Pressure checked periodically and take your treatment
regularly. You should also consider for low salt diet.
C. High cholesterol? - Are you taking any medication for that?
Obesity
- Do you know anything which may be responsible for this weight gain?
Thyroid cold intolerance, hair loss
CVS-RS, GI, CNS, Metabolic- DM ,Ortho
1. Depression
2. Hypothyrodism
3. Cushings syndrome
4. Polycystic disease
5. Sedentary lifestyle
6. family h/o

2. Allergy Do you have any allergy? Which allergy do you have? what kind of allergic reactions
do you develop?
3. Medicine Are you taking any medications (Apart from ........./ told before)?
(Which medications are you taking?
Since when are you taking these medications?
Why are you taking these medications? )
4. Hospitalization, Surgery, Trauma Have you ever been hospitalized before? [for what?]
Have you ever had any surgery before (Apart from.)? Any major injury in your life ?
5. Urination F-U-N- C-B-P- H-S-F-R-I
1. Change Do you have any problem with your urination?
2. Frequency - How often do you go for urination?
3. Nocturia - Do you wake up at night for urination?
4. Urgency - Do you have to rush for urination?
5. Burning - Do you have any pain during urination?
Do you have any burning during urination?
6. Color what is its color?
7. Blood Is there any blood in urine? Any Pus in it?
[8. Hesitancy - Do you have to wait to start urination?
9. Straining - Do you have to strain to pass urine?
10. Flow - How is the flow of urine? I Mean continuous or dribbling
11. Incomplete evacuation do you feel that your urinary bag is not empty even after
urination?]
12. Control - Have you ever passed urine without your notice?
6. GIT F- C- C-B-P- S-R-I
1. Change Do you have any problem with your bowel movements?
2. Frequency - How many bowel movements do you have?
3. Consistency- What is its consistency?
5. Color - What is its color?
6. Blood - Is there any blood in it? Any pus in it?
7. Pain - Do you have any pain during bowel movements?
8. Straining - Do you have to strain during bowel movements?
9. Incomplete evacuation - Do you feel that your bowel is not empty even after your bowel
movements?)
10. control have you ever passed stool without your notice?
7. Sleep
1. Do you have any problem with your sleep?
{Do you have problem in falling asleep? Staying with sleep? Do you wake up early in the
morning?
(2. How many hours do you sleep?
3. Do you feel refresh when you wake up?
4. Do you feel sleepy during day?
5. Do you snore at night? If insomnia case)}
Falling- What do you do before going to sleep? -watch tv, heavy meal, coffee, exercise?
When do you usually go for sleep? How much time do you take to fall a sleep?
Staying How often do you wake up at night? Do you know anything which may?

8.Family History
Well, Mr. ______ Now I am going to ask some questions about your family health. Is that ok?
Does anyone in your family have similar complain?
How are your parents doing? [If died, -Oh! I am sorry to hear that. But can you tell me the
cause of his/her their death? If fine,- glad to hear that]

9. Gynecological History
Well, Mizz.______. Now I am going to ask some questions about your gynecological health. Is
that ok?
1. When was your last menstrual period? Are your periods regular?
(4. How many days are there in between your cycles?
5. How long does your period lasts for?
6. How many pads do you need?
7. Do you have any pain during menstruation?
8. Have you ever bleed in between the cycle?
9. Have you ever gone through PAPs smear examination? What was the last result?)
Obstetric History
How many times have you become pregnant?
How many kids do you have?
Have you ever had any abortion? In which month/week of pregnancy? Do you know the
reason for that?



10. Sexual History
Well, Mr. ____, now I am going to ask you some questions about your sexual health.
I want to assure that our conversation will be kept confidential. Is that ok? )
(Mr. ______, sometimes hidden clues can be found by such kind of information, which may
help me in your diagnosis. Is that ok?)
a. Are you sexually active? (No) May I know why it is so? Do you have problem with desire ?
erection?
b. How many sexual partners have you had in last one year?
What is your partner preference? I mean male, female or both?
c. Do you use any mean of protection? ( Condom? Birth control pills? )
d. Do you use it regularly? (No) may I know why it is so?
e. Have you ever been diagnosed with Sexually Transmitted Disease? Was it cured completely?
f. Have you ever been tested for HIV? What was the result?
g. Do you have any penile / vaginal discharge? Since when? What is its color? Is it foul
smelling?
Sexually promiscuous patient with unprotected sex
Mr. ______ as a concerned physician I must inform you that multiple sexual partners and
unprotected sex may put you at high risk of sexually transmitted

so I recommend you to should use condoms each times you have sex. if male
so I recommend you to insist your male partners to use condoms each times you have sex. if
female

I am glad to hear that you are practicing safe sex. And I hope that you will also use thenm
regularly in future.




[STD
is sexually transmitted disease which may acquired from your partners
So it is needed to test and treat all of your sexual partner as well otherwise you will be at risk of
contracting infection again.

You should also avoid sex till the treatment is completed.

I recommend you to should use condoms each times you have sex.- if male
I recommend you to insist your male partner/s to use condoms each times you have sex. if
female.


HIV counseling
Mr. _____, you are at a risk of getting infections. So you should take appropriate vaccines to
prevent such disease.

I also recommend you for regular follow-ups and early treatment of any such illness .

We have an excellent support group, who will help you to tackle your emotional & social issues.
I will give their contact number to you.]


11. Social History / Personal History T A R A W O T S (TOBACCO, ALCOHOL, RECREATION
DRUG, APETITE, WEIGHT, OCCUPATION, TRAVEL, STRESS)
Well, Mr. _____ now I am going to ask some questions about your personal habits. Is that ok?
Smoking
i. Have you ever smoked? Since when?
ii. How many packs per day do you smoke?
Alcohol
i. Have you ever drink alcohol? Since when?
ii. How much alcohol do you drink?

(Cut Have you ever tried to cut down your drinking?
Annoyed Have you ever annoyed by criticism of your drinking?
Guilty Have you ever felt guilty about your drinking?
Eye opener Do you take alcohol in early morning?) if binge drinking
Drugs
Have you ever take any recreational drugs? Since When?
How do you take it? I mean do you inject or smoke it?
Smoking / Alchohol
Mean while I strongly recommend you to quit smoking and/or alcohol as it can damage your
heart and blood vessels. We have excellent support group who will help you, whenever you
want to quit it. I will give their contact number to you.
I strongly recommend you to quit smoking and/or alcohol as it can damage your heart and
blood vessels. Do you want to quit? (the smoking/alcohol)?
(yes ) I am glad to hear that. We have excellent support group, who will help you in this matter.
I will give their contact number to you.
(no ) I can understand that. But whenever you want to quit, then I will be here to help you.
Please collect my contact number from my nurse outside.
(I had tried quite but it didnt worked- Mr. _____ I can understand that. It happens to most of
the people.
If no smoke/alcohol I appreciate that you are taking good care of your health as smoking
and alcohol can damage our heart and blood vessel.
If quit - I am glad to hear that you have stop .. as smoking and alcohol can damage our
heart and blood vessel.)
Appetite
Is there any change in your appetite?
Is there any change in your weight ?( How much? Over what period of time?)
Do you feel fatigue? If yes- thyroid
What do you do for living?
Have you traveled recently?
Do you exercise regularly?
Do you have any stress in your life?
{ How is your mood whole a day?
May I know with whom do you live ? How is your relationship with them? (elder)
Do you have any contact with person with similar complain? ( ill contact exposure infections
like TB, Pneumonia, diarrhea etc.)}












PHYSICAL EXAMINATION
Well Mr. .Now I need to examine you. Before that would you like to tell me anything else?
Ok, then Let me wash my hands first. Excuse me. (Ask about work, travel, exercise)

Can I proceed with your examination?
If pain occurs- I AM SORRY, I WILL NOT REPEAT THAT AGAIN.
Patient resisting for physical examination
Mr._____, I can understand your concern. But the physical examination I want to do is very
important to determine what is causing your complain. I will be quick and gentle as possible.
And I will inform you whatever I am going to do.
If ask for pain medication-
Mr._____, I can understand your concern. First of all I would like to examine you. Once I find
out exact reason for your pain, I will able to give you something to feel you comfortable.
General Examination not in HEENT and NEURO
("PICKLE" ( Pallor, icterus,) (Cyanosis, Clubbing, Koilonychia,) Lymphadenopathy and Edema Feet" )
Let me start with your eyes.
Can you please look up? Look down? Thank you.
Please open your mouth. Stick out your tongue. Say Aaah for me. Thank you. (9,10)
I am going to check your neck for any swollen glands.
Now I am going to check your special gland which is called thyroid.
Please show me your hands. Your nails. Let me check your pulse. Thank you.
Well. Mr.........Now I am going to examine your legs. For that I need to raise your drape. Is that
ok? I am checking for swelling. Let me check your pulse. Thank you. Let me cover it again.

HEENT
Head I am looking at your head for any abnormalities.
Face I am going to press on your face. Let me know if it hurts. (Sinus tendernees. - frontal and
maxillary)
Eye vision acuity, EOM {PERLA, Fundoscope - (dim light) HTN, DM -Follow up, vision problem}
Please cover your Right eye- Can you please read the smallest line you can? Thank you.
Now cover your left eye. You may uncover your eye.
Can you please follow my finger without moving your head? Thank you.
{Now I am going to check your vision with the instrument called Fundoscope. Excuse me for a
while.
3. Now I am going to throw light in your eyes. Can you please see at that wall?
4. Fundoscopy - Now I am going to look inside your eyes. }
Ear I am looking at your ear for any redness.
I am going to press your ears. Let me know if it hurts.
Now I am going to check your ears with the instrument called Otoscope. Excuse me for a
while. (change the speculum)
now I am going to look inside your EARS, NOSE
{ 8 nerve - Deafness
Weber- Now I am going to put this tuning fork on your forehead. Can you hear it? Does it
sound same or different in both ears?
Rinne- Now I am going to put this tuning fork on front and back of ear. Then tell me
which one sounds better?}
Nose I am going to check your nose for any discharge.
Throat - Please open your mouth. Stick out your tongue. Say Aaah for me. Thank you
Neck I am going to check your neck for any swollen glands.
Now I am going to check gland of your neck which is called thyroid. Can you please swallow for
me? Thank you.
Respiratory system
Now I am going to examine your chest. For that I need to untie your gown. Is that ok?
Inspection
Now I am looking at your chest.
Palpation-
Now I am going to press your chest. Let me know if it hurts.
Can you please say 99 repeatedly, when I touch your chest?
Now I am going to check your breathing movement. Can you please take deep breaths for me?
Percussion
Now I am going to tap on your chest.
Auscultation
Now I am going to listen to your chest. Can you please take deep breaths for me? Thank you.
You may relax now.
Now I am going to listen to your heart. Can you please stop your breath for a while?
(Auscultate aortic- pulmonary- tricuspid- mitral areas.) Thank you. You may relax now.
Let me tie your gown.







CVS
(check radial, dorsalis pedis and edema in general examination)
Now I am going to examine your chest. For that I need to untie your gown. Is that ok
Inspection
Now I am looking at your chest.
Palpation-
Now I am going to press your chest. Let me know if it hurts.
Now I am going to feel your heart beat.
Auscultation
Now I am going to listen to your heart. Can you please hold your breath for a while?
(Auscultate aortic- pulmonary- tricuspid- mitral areas.) Thank you. You may relax now.
Now can you please lie down for me? Let me help you. Thanks.
Now I am looking at your neck for any dilated veins.( jvp)
Now I am going to check pulse in your neck.
Now I am going to listen to your neck for any abnormal sound. (carotid bruit)
Now I am going to listen to your heart. Can you please stop your breath for a while?(auscultate
4 areas.) You may relax now.
Now you can sit up. Let me help you.
Now I am going to listen to your chest. Can you please take deep breaths for me? Thank you.
You may relax now.
Let me tie your gown.



Abdomen P/R EXAMINATION in closure
Now I am going to examine your belly. For that I need you to lie down. Let me help you. Thank
you. (pull foot rest out)
Now I need to raise your gown. Is that ok?
Inspection
Now I am looking at your belly.
Auscultation
Now I am going to listen to your belly.
Percussion
Now I am going to tap your belly.
Palpation
Can you please bend yours knees for me?
Now I am going to press your belly. Let me know if it hurts.
Now I am going to press your belly deeply. Can you please take a deep breath for me?
Now I am going to press your belly and then release it immediately. Let me know if it hurts on
pressing or releasing? - Rebound tenderness
Thank you. Now you can cover your gown. Let me help you.
Ohk, Mr.______. Now I need to examine your back. For that I need you to sit up. Let me help
you. (push foot rest inside). Now I need to untie your gown. Is that ok?
Now I am going tap your back, let me know if it hurts. - costovertebral tenderness
Let me tie your gown.
Appendicitis
Psoas sign Can you please move your knee towards your chest against my hands? And Let me
know if it hurts. (flexion of hip)
Obturator sign I am going to move your knee. Let me know if it hurts. (internal rotation of hip)
Rovsing sign I am going to press your left side of belly. Let me know if it hurts on right side.
Cholecystitis-
murphy's sign- I am going to press your belly. Can you please take deep breaths for me? And
Let me know if it hurts?
CNS
MMSE Depression, Dementia
Okay, Mr. _____ now I am going to ask you some questions to check mental function.
1. What is your full name? What is the date today? Where are we right now?
2. Now I am going to tell you three words. I want you to repeat them immediately and after
some time, is that ok?.cat, apple and table
What is the importance of 4th July? - (Independence Day)
3. Can you please count down from 7 to 1?
4. What would you do, if you see your friends house on fire? - (call 911)
5. Can you please repeat those three words for me?
Cranial nerves
Now I am going to check your nerves
Do 2, 3-4-6, 7, 9-10-12, 5, 8, 11
II - Please cover your Right eye- can you please read the smallest line you can? Thank you. Now
cover your left eye. You may uncover your eye.
III, IV and VII - Can you please follow my finger without moving your head? Thank you.
VII- Can you please raise your eyebrow, smile for me? Thank you
V -can you please clench your teeth for me?
VIII - Can you please close your eyes? Can you hear this?
IX, X, and X, XII- Please open your mouth. Stick out your tongue. Say Aaah for me. Move Side to
side. Thank you
XI -Can you please shrug your shoulders against my hands?


MOTOR
Now I am going to check your muscle strength.
Upper limb

Please hold my fingers tightly and pull it towards your side and push it towards my side. Thank
you.

[Wrist Can you please pull up? Push down? Thank you.
Elbow Can you please pull in? Push out? Thank you.]
Lower limb
Knee Can you please kick out? Pull in? Thank you.
[Foot Can you please pull up? Push down? Thank you.]
REFLEX
I am going to check your jerks. Biceps, (Brachio radialis) Knee, (Ankle)
SENSORY
Now I am going to check your sensation.
See this is sharp and this is dull. Now please close your eyes? And tell me which one is sharp
and which one is dull?
4 face areas (forehead, cheek) , arm(hand) leg (foot)
Cerebellar test- Now I am going to check your balance.
Finger nose test Please take your right finger. Now touch my finger and then touch your nose
repeatedly. Now repeat it with your left finger.
Gait - Now I need you to walk few steps for me. Let me help you (pull out foot step). Please be
assure that I will not let you fall down.
Now please turn and come back.
Romberg test Please stand with put your feet together. Now close your eyes.
Special test-
Kernings sign- Can you please bend your thighs and knee. Now I am going to move your knee.
Let me know if it hurts.
(flex both knee and hip, then try to extend the knee only.)
Brudzinskis sign- Now I am going to bend your neck. (When you flex the neck, there may be
flexion of hip and knees)

SPINE
Now I am going to check your back. For that I need to untie your gown. Is that ok? Thank you.
inspection
Now I am looking at your back for any abnormality,
palpation
Now I am going to press at your back. Let me know it hurts. (cervical, thoracic, lumbar, sacral.)
range of motion
Now I am going to check movement of your back. Can you please bend forward, backward,
sideward, move side to side? flexion, extension, lateral flexion, twisting.
gait
Now I need you to walk few steps for me. Let me pull out foot step for you.
Now please turn and come back?
Motor, reflexes, sensations
lower limbs
Pulsations
SLR

Closure
All right, Mr._____, thank you for you kind co-operation. Now let me tell you what I think so far.
First of all, let me summarize.
As you told me that you have.is that right?
According to the information I got from you and from the examination, I am considering the
possibilities like you may have..or.
But to confirm the diagnosis, I need to run some tests like blood test and scanning of
your________ . if ABD- P/R Exam . if gynec Pelvic Exam
As soon as I get the results, we will meet again. And at that time I will explain you in the details
and we will also discuss the treatment options. Is it ok?
Do you have any questions for me? If you have any question later on, you can call me at any
time.
I hope you understand what we discuss today.
It was nice to meet you. Bye. Take care. (shake the hand with smile and leave the room )










So doc I have....?
Well mr....... I can understand your concern, but first of all I would like to do physical
examination and run some tests. Once the test results available, I will be in better position to
tell more about it. / We have to wait till results to find out what exactly wrong going with you.
(Well mr.......From complain you have told there is less chance of......... but first of all
Well mr......, It may be one of the possibilities. But there are also other conditions which
mimics your complains. So first of all.)
Cancer?
Mr.I can understand your apprehension. Some cancers are hereditary. But that does not
mean that you will get it.
So am I going to die?
Mr.I can understand your apprehension. But I want to assure that here you are in the safe
hands and we will do our best to feel you better.
Am I going to get better?
Mr. I can understand your concern. There are number of conditions which mimics your
complains and many of them are treatable.
Angry
I am sorry that I keep you waiting. Actually we had some unexpected delay with earlier
patients. But right now I am here and I will focus on you and your concerns. And I will also keep
in mind that it will not happen again.
Over talkative patient-
Excuse me Mr______. I can understand that those issues are important to you. But right now I
want to focus on you and your current problems. come to the problem where stop.
If want to ask again -I am sorry. Can you please repeat it again what you have just said?
if time is over before,
Oh. I am sorry. We have an emergency. I have to leave. I will be back as soon I can.
PSYCHIATRY
General
Mr._______ you seem to be upset. Will you please share it with me? I am here to help you.
Mr._________ I really want to help you and for that I need to understand your problem. Can
you please tell me what happened to you?
I want to die doctor I can understand that its hard time for you. But running away from the
problem is not the solution. We can deal with it to gather in much better way.
Etiology
Do you know anything which may be responsible for this?
Any emotional problem? Any family problem? Any financial problem?
Do you have trouble in adjusting with the temperature? Have you notice any change in your
hair?skin?
support May I know with whom do you live ?
Is there any one in your life to help you/ for your help?
DEPRESSION (FACE SLIPS)
Feeling of guilty Do you feel guilty about anything?
Appetite Is there any change in your appetite, weight?
Concentration Do you have any difficulty in concentrating? Memorizing things?
Energy How is your energy level?
(Sleep Libido )
Pleasure level Are you able to get interest in those activities which you were enjoying in the
past?
Suicidal ideation - Have you ever thought about hurting yourself or ending of your life? Do you
have any plan for that? Have you ever tried to do so?
Hallucination Do you hear anything that other people cant? what are they telling?
Do you see anything that other people cant?
Delusion Do you have belief that other people find odd?
Do you have any belief that other people are trying to harm you? control you?
Counseling
Your problem is common in our society and you are not alone.
You can call me at any time whenever you feel worse. I am here for your help and support.
We have excellent counselor and support group who will help you in this matter. I will give their
contact numbers to you.

DEMENTIA
Do you have any problem in remembering names, phone numbers, keys, turn off stove, ?
Do you have problem in performing daily activities? Like
DEATHDo you need any help in getting dressed [dressing]? Eating [eating]? moving from
your bed to chair [ambulation]? Going to bathroom [toileting]? [ Have you ever had any
accident with urine or bowel movement [hygiene]?]
SHAFTDo you need any help in shopping [shopping] ?, cleaning your house [house keeping] ?
Managing your money [accounting] ? cooking [food preparation] ? moving from one place to
other [transportation] ?
Counselling
I need your permission to talk with your caretaker who can help me with your diagnosis.
We have excellent counselor and support group who will suggest you about home safety
measures. I will give their contact numbers to you.
Meanwhile I will remain in contact with you for your help and support.

ABUSE S-A-F-E G-A-R-D
support May I know with whom do you live?
How is your relationship with them?
Well Mrs. I am concern about your safety and I want to make sure that you are not victim of
abuse.
Safe - So are you safe at your home?
Well Mrs. I want to assure that our conversation will be kept confidential.
So can you tell me what exactly happen to you? How often does it happen?
(So does anyone in your life have hurt you physically? Emotionally?)
Afraid of Are you afraid that it will happened again?
Family aware - Are your relatives aware of your condition?
Emergency plan- Do you have any plan to leave your home?
G- Is there any weapon at your home?
A- Does your husband drink alcohol?
R-
D- How is your mood whole a day?

How many kids do you have? Are they being hurt?
Counseling
I am concern about your safety. I am here for your help and support.
Please assure that whatever you have told will be kept confidential.
We have excellent counselor and support group who will help you in this matter. I will give their
contact numbers to you.
Moreover I must inform child protective services if your child is being abused.
Pediatric case
Good morning. I am Dr. Mehta. I am physician in this hospital. May I have your name please?
(May I know to whom I am talking to?)
Ok. Miss..today I will ask you some questions about your childs health. is that ok?
During our conversation if you have any concern then please let me know.
So Mrs.______, How can I help you today?
Oh I am sorry to hear that your child has.
Can you tell me more about it?
Onset When did it start?
Progress - -So as you told me that you have.. Then is it remaining same or getting worse?
[Does he attend day care center? Is there any ill contact over there?
How does he look like? Playful, tired, irritated?
How does he cry like? Vigorous, weak?]
[Is there any fever? Vomiting? Rash?
Cough, problem with breathing? Running nose? Ear discharge? Difficulty swallowing
Shaking?]

Well, Mrs. _____, now I am going to ask some questions about ...'s Past Medical Health. Is
that ok?
P/H Was there any similar complain in the past?
Does he have any allergy?
Are you giving any medications to him? Like multivitamins?
Was there any hospitalization before? any surgery before?
Is there any problem with urination? Bowel movement? Sleep?
Pre natal ,natal postnatal History
All right, Mrs. ..Now I am going to ask about .........'s birth and your pregnancy. Is that ok?
Did you get routinely checked during her pregnancy?
Were you smoking during pregnancy? Taking alcohol? Recreation drug? Medications?
Was there any problem during pregnancy?
What was the mode of delivery? I mean normal delivery or cesarean?
Was the baby full term? If no- At which month of pregnancy did you give birth ?
Was there any problem during delivery? After delivery?
(When did he first cry after delivery?
When did he pass his first stool?
When did he start his first feeding?)

Feeding history
Was the child breast fed or bottle fed?
What does he eat now?
Is there any change in his appetite? Weight?

Developmental history
Is his current (he gaining) weight/ height appropriate to the growth chart?
Does his weight/ height follow the growth chart?
When did he first smile? First crawl? First walk?



Routine care
When was his last check up? How was his health at that time?
Immunization Are his immunizations up to date? Do you have vaccination card with you?
I am glad to hear that you are taking good care of your child. As vaccine can protect him from
many illness.
(not taken) May I know why it is so? Mrs.....As a concerned physician I must inform you that
vaccine can protect him from many illness. So I strongly recommend you to complete his
vaccination as soon as possible.
(And this kind of vaccines are given free of charge by federal government health program- if
financial reason)

CONCLUSION
All right, Mr. Smith,_____ thank you so much for you kind co-operation.
Now let me tell you what I think so far. First of all let me summarize.
As you told me that he hasis that ok?
Would you like to tell me anything else, Mrs.______?
According to the information I got from you/ from that, I am considering possibilities like
But to confirm diagnosis, I need to examine him/her and run some tests like.... For that I want
you to bring your child to the hospital. Do you need any mean of transportation?
At that time I will explain you in details and we will also discuss about treatment options? Is it
ok?
Do you have any questions? If you have any question later on, you can call me at any time.
I hope you understand what we discuss today.
It was nice to meet. . Bye. Take care.
PICKY EATER
So why do you think that your kid is picky eater? I mean
Does he have any specific preference to food?
Since when are you noticing this behavior? - O
Is it remaining same or getting worse? P
Have you give any treatment for that? Like scheduling meal time?
What is your response to this behavior? Have you ever punish / reward him?
How is it affecting your childs life?
Does he watch TV during meal?
Does he take high calorie drinks like soda, juice in between the meal?
Do you have any other concern beside this?

Counselling
Well Mrs. .., from the information I got from you, I feel that your son is probably going
through normal phase of behavior.
However to confirm my diagnosis

It is the common problem in this age group and it responds well to few behavior changes.
First of all, I suggest you to strictly follow meal schedule for your child.
Do not allow him to watch tv during meal.
I also recommend you not to give high calorie drinks in between the meals.
Regarding constipation, you should give him high fiber diet and plenty of water.
Causes
- low fiber diet
- hypothyroidism
- lead poisoning
- ADHD
- Oppositional defiant disorder
Investigations
- CBC, ESR
- T3, T4, TSH
- Blood lead level
- Blood calcium level
- Stool for ova and parasite












Enuresis
- How often does it occur?
- Urine h/o - Frequency, urgency, color, blood, pain - Does he cry during urination? UTI
-Bowel h/o - Frequency, consistency, color, blood, pain - Does he cry during Bow mov? - Consti
- Does he snore at night? sleep apnea
- Does he have any stress? Does he have problem with walking? - secondary
Have you give any treatment for that? Like bed alrm
What is your response to this behavior? Have you ever punish / reward him?
How is it affecting your childs life?
- Family h/o
Counseling
It is the common problem in this age group and it responds well to few behavior changes.
You should not give more fluid at bed time.
You should also take him for pee before going to bed.
Causes
-Primary nocturnal enuresis
-Secondary nocturnal enuresis
-UTI
-constipation
-Obstructive sleep apnea

Investigations
- P/R examination
- CBC, ESR
- UA
- USG kidney
- CT ABD

Temper tantrum
- How often does it occur?
- Can you tell me what happens at that time?
Does he hold his breath?
Does he harm himself during it?
- Do you know anything which may be responsible for this ? like fever? Pain? Missing meal?
Travel? New surrounding?
Have you give any treatment for that? Like scheduling meal time?
What is your response to this behavior? Have you ever punish / reward him?
How is it affecting your childs life?
Counseling
It is the common problem in this age group and it responds well to few behavior changes.
I advise you to keep his routine regular.
You should consider for TIME OUT.
Causes
-Normal growth and development
- ADHD
- Autism
-Depression
- Seizures, arrhythmia passes out

Investigation
- CBC, ESR
- EEG,
- CT Brain
- MRI Brain
- Echocardiography

Patient note - Physical Examination

Patient in distress /not in distress
Vitals : WNL (except ..)
NECK
No lymph node, thyroid enlargement
EXTs
No cyanosis, clubbing, edema
Pulse 2+ BL equal in all exts.
HEENT
Head: NC/AT, Non tender
Eye: VA 20/20 in both eyes,
EOM intact
Ear: No visible abnormalities, Non tender, No ear discharge, TM - WNL BL
(Weber Test: No Lateralization. Rinnes test: AC>BC in both ears.)
Nose : No nasal Discharge
Throat : Tonsils WNL BL

CNS
A + O x 3
Cranial Nerve: II to XII intact
Motor: strength 5/5 in all muscle groups.
Sensation: Intact to sharp & dull BL in all exts.
DTR: 2+ BL equal in all exts.
Cerebellum: Finger to Nose intact, (-) Romberg Sign
Gait Normal
MMSE
A+O x 3
Memory: Immediate, Recent & Remote intact
Concentration : good
Judgment: Intact

RS
No visible abnormality
Non tender, Breathing movement BL equal, TVF WNL
Resonant to percussion
Chest -clear to Auscultation.
(-) Rales, Ronchi, Rub
CVS
No visible abnormality
PMI Non displaced
S1,S2 (+) , (-)Murmur, gallops, Rubs
No JVD, Carotid Pulse +2 BL, (-)Carotid bruit

ABDOMEN
No Visible abnormalities
(-)Bruit, BS (+)
Tympanic to percussion in all quadrants
Soft, Non tender,
No Masses & organomegaly, No CVA & Rebound tenderness


SPINE
No visible Abnormality
No tenderness
ROM: intact/ not elicited due to stiffness/pain
Gait :NL
Motor: strength 5/5 in both legs.
Sensation: Intact Dull & sharp in both legs
DTR: 2+ Intact in symmetrical in both legs.
SLR (+)

Examination Timing
General Examination: 1 min
HEENT: 3:20 min
CVS/RS: 2min
GIT: 2 min
CNS without MMSE: 3 min
MMSE: 1 min.
Closure: 1:15 Min



"Failure is the opportunity to begin again more intelligently." - Henry Ford