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CS Clinical Encounter.

(Typical Sheet)
History Taking.

 ( Knock the door 3 times, then partially open the door )--- you knock on the door
before entering to let the patient know you are entering - and not to ask for
permission –

1. HELLO, Mr /Ms Last name? Did I say your name right?(If it’s a complicated name)

2. My name is Dr……….. ,I am the Physician in the office today, (While Shaking Hands If
Appropriate) It’s NICE TO MEET YOU.(If the pt. is angry ,in discomfort, distress or
severe pain-Don’t do Hand shaking

3. I’m here to do a physical exam and ask you some questions, is it ok?
 First, let me cover you to make you more comfortable(Better) OR

 Are you comfortable in this room ?May I put this drape on your lap-Thank You

(Drape the patient: must be before the examination but do it now better)

4. Do you mind if I( sit down and) write some notes while we talk? Thank you.(Optional
as in real life you are taking notes without permission)) (NOT SAID IN EMERGENCY

5. , "So Mr. Last Name, How can I help you today?" OR

What medical problem that brought you here?

6. Show Sympathy After The Chief Complaint {Oh, I am very sorry to hear (that/about
your situation/about what you are experiencing),

I assure you that I will do my best to help you (today/”In this Regard”) , Okay?
OR I’m gonna do everything I can to {help you “feel better” today/ resolve this issue}

7. Could you please tell me more about your PROBLEM?(1st open ended Q)

Don’t cross your arms in front of your chest when talking to the patient, espe-
cially with the clipboard in your hands. It’s best to sit down on the stool, relax,
and keep the clipboard on your lap. If you decide to stand, maintain a
distance of approximately two feet between yourself and the patient.

To justify your silence say: I’m just taking some notes to keep tracking of what we are
talking about so we can help resolving this problem
For All Cases : OCCCPDF + AAA
For Pain/Headache: LIQR+ OCCCPDF + AAA
For (Any Fluid Coming From The Body:e.g Vomiting-Diarrhea-Cough(with Phlegm)-Vaginal
discharge-Blood)+Constipations , (OCCCPDF+ABCO)

ABCO stands For (Amount-Blood-Color-Consistency– Odour )

Amount: How much is the phlegm/blood/vomit? Was it
A teaspoon=5cc? A tablespoon=15cc? A cupful=240cc?”
Blood: “Have you noticed any blood in it?”
Color: what color was the vomit/discharge/stool?
Consistency: How did it appear? Was it watery ,fatty or bloody?
Odour: How did it smell? Any Specific Odour?

(Any PAIN)
Location: Can you show me exactly where it hurts? /Can you point to the pain?

Intensity: On a scale from one to ten being ten is the worst, how do you rate your pain?
Oh that sounds very painful I am sorry for that, I will do my best to make you feel better.

Quality: How would you describe your pain? How does it feel like?-(If pt doesn’t answer)
clarify more by these: Is it burning, throbbing, stabbing, stitching, cramping, dull aching?)

*Onset: When did it start? Or For how long you have had this?

*Context=Description: What were you doing when it started? Or anything in particular

happened before this started?

*Course: Was it sudden or happened over time?

*Progression: Is it getting better or getting worse?

Constant Or Intermittent: Does it come and go or it is constant?...If said intermittent,ask

*Duration: When you have the pain, how long does it last?
*Frequency: How often do you have the pain? Or How frequent does this occur?

Radiation: Does the pain Move/ Do you feel it (pain or any symptom) anywhere else?

Aggravating Factors: What makes your pain worse? Or “What brings the pain on?”

Alleviating Factors: Anything in particular makes it better?

Common factors {specific position-rest or exertion-time of the day-medication-meals-period}

Impact on the patientImp to ask

 Does this (Pain-Fatigue-…etc) interfere with your sleep?
 How does this (pain) affect your daily activities or your job?

Associated Symptoms Divided Into two parts:

1- System Related Qs.(e.g. Joint Pain – Ask About musculoskeletal system history )
2- DD Based Qs(Fever-Chills-Night sweats/Headache/Throwing Up/Tingling ,…etc)

e.g. *Associated symptoms for cough (General + URTI+ LRTI symptoms )

For Any Pain (Always ask about the sympathetic response: Sweating-Nausea-Vomiting)
Review Of Systems(ROS): (Main + General + DD) not more than this in any history

1. General(Constitutional)
Have you had any recent infection? Any fever? Any night sweat?
Do you feel tired?
Endocrinal Questions:
*Do you (feel uncomfortable)(have any discomfort) in hot temperature/in cold temperature?
*Have you noticed any changes with your skin? With your hair? With your voice?
Sleep: How is your sleep? Then How many hours? Do you have any trouble (Falling/Staying)
asleep? /Do you wake up(throughout the night/Early in the morning) Do you(snore/take naps)

2. HEENT {URI (runny nose, sore throat, cough)}

Have you had any headaches? Have you had any sinus infection? any light-headedness? Have you
had any trauma to your head?
Eyes: Have you noticed any changes in your vision? If yes, do you see flashes of light?
Nose: Do you ever have any nosebleeds? Do you have runny nose?
Ears: How is your hearing? Do you feel that the room is spinning around you? Do you hear any
ringing in your ears? Do you feel any (pressure /pain) in your ears? Do you have discharge from
them? Did you put anything in them? Have you been exposed to loud voices?
Throat: Have you had any sore throat? Have you experienced any difficulty swallowing?

3. Neck
Have you ever noticed any (lumps/swellings) in your neck? Any neck stiffness?

4. Cardiovascular
Do you feel your heart is beating fast? Was your heart racing?
Do you have any chest pain? If so, analyze + do you have it at rest or with activity? Do you
have it when you are breathing in?
Do you have difficulty walking up the stairs?

5. Respiratory(Do you have any difficulty breathing?)

Are you ever short of breath (SOB)? If so, when, by day or by night?
Do you have noisy breathing=wheezes?
Do you have a cough? If so, is it dry or anything comes out? Have you coughed blood before?

6. Gastrointestinal(Have you had any changes with your bowel movements lately?)
“Do you have diarrhea?” And “Are you constipated?” and for how long? (If No-Ask the rest)
Do you feel nauseated? Did you throw up?
“Do you feel any pain in your belly?” /”Have you had any (blood, mucous) in your stool?”
Do you have pain with defecation? Do you have the urge to pass stool and you don’t do it?
Appetite: How is your appetite?
Diet : Are you (following/on) a special diet?
Weight: Have you had any recent weight loss or weight gain? How many pounds?
Over (what period of time?/How long of period) Was it Intentional?

8. Urinary(Have you noticed any changes with your urination?) If No---No more Qs
(Irritative symptoms: Dysuria, frequency, nocturia, urgency)
Do you have any burning sensation with urination? Have you noticed any blood in your urine?
Did you notice any increased frequency of urination? How many times do you get up by night
Do you ever feel that you must pass urine immediately & rush to the bathroom?
(Obstructive symptoms: Poor stream-terminal dribbling- Hesitancy -stranguary)
Have you noticed any reduced force of your urinary stream? Any dribbling of urine? (Male Q)
Do you ever have any difficulty in starting urination (hesitancy)?
Do you need to strain/push during urination?(Stranguary)”

Have you ever lost control of your bladder? (Incontinence/Both Males& females)

9. Musculoskeletal (Do you have any other painful joints or bony pains or aches?)
Does your (Knee-wrist-fingers) feel stiff in the morning/in the evening?
Is there any redness on your Joint? Is it swollen?
Is it warm to the touch?
Do you hear any crackling sounds when you move it?
Have you been hiking recently?

10. Hematologic
Have you had a rash recently? If yes, can you describe it to me?
Do you bruise easily?
Have you ever had a blood transfusion for any reason?

11. NeuorologicalWeakness-Walking/Seizures-Speech
Are you having any difficulty (walking=with your balance)? Any difficulty with your speech?
Do you feel weakness anywhere? Any numbness?
Do you have difficult time getting up from the chair? (Proximal weakness)
Did you have any shaking movements? If Yes --Did you bite your tongue?
Do you ever feel dizzy? Do you fall easily? If yes, did you injure your head? Any LOC

12. Psychiatry:
How about your mood? Do you know why do you feel this way?
Followed by Depression Questions +/- Psychosis Questions.(mainly hallucination/suicide)
Past History: (PAM HS FOSS):Transition statement *Okay Mr. / Ms. Last name, now I
would like to ask you few questions regarding your health in general, is that okay with you?

1- Previous episodes or Past Medical diseases:

1-Have you ever had this before? Followed By
2-Do you have any other medical diseases/problems? (pause as it’s open ended Qs) then
say Like High “ Blood pressure, blood sugar, cholesterol”?

2- Allergy: Are you allergic to any medications? To any food, to anything else?
3- Medications: Are you currently taking any prescribed medication? How about over
the counter medications? How often do you take them? /Do you take birth control pills?
4- Hospitalization: Have you ever been hospitalized? What for?
5- Surgery: Have you done any surgeries before?
6- Family History: (Transition) Okay Mr. /Ms Last name, now I would like to ask about
your family health, is that okay with you?
1- Are your parents alive and well?
*NO--Sorry for (that/your loss), *If diseased: hope s/he gets well soon.
Do you know the cause of his/her/their death? OR It must be very struggling for her/you.
2-Does anyone in your family have similar symptoms?
3-Do you have a Family history of cancer, mental illness or any medical disease? (Optional=
if relevant)
OB/GYN History:Okay Ms Last name, now I would like to ask you few questions regarding
women health, Is that okay?
(Non Ob/Gyn Case) (Ob/Gyn Case)
Female in Child bearing Period: Menarche/ LMP/ Length/Description/ Clots(=heavy) /
period No. of Pads/Pain during menses/Cramps
*When was your LMP? Cycle: Regularity/Break through bleeding/
*Are your Cycles Regular? Bleeding: Context/ Duration / Amount =No. of pads/ Clots
*Have you had PAP Smear Discharge: Analyze it(ABCO) / Itching
before? when was last one? Intercourse Do you have any pain during it? Any bleeding
was it normal? during or after it? , How soon did you bleed?
Female in menopause: Urinary System: Do you have any problems with urination ?
*Any vaginal bleeding
*Any discharge/Itching Obstetric History
* Have you ever had any *Have you ever been pregnant? How many times?
abnormal PaP smear? *Have you ever had any miscarriages? How many times? Do you
* Any hot flashes. remember in What trimester?
* Any mood swings. *How many children do you have?
*Have you ever had any complications with your pregnancy?

Sexual History: (Transition):Note That Not All Questions Will Be Asked.

Okay Mr/Ms Last name, now I would like to ask you few questions regarding your Personal
Life, be sure that whatever you tell me will be kept confidential, Is that okay with you?
1- Are you sexually active? If Yes With whom?(If said with my wife–no more Qs)
If anything else ask for how long you have been with her/him?
If said for less than one year Then Ask
2- Do you use any kind of protection? Do you use it regularly?
3- Have you had any other sexual partners during the last year? men or women
4- Have you ever had any sexually transmitted disease? (A must)
Have you ever been tested for HIV?(For Multiple sexual partners/symptom
related disease)

Social History : {TIA WT ELSS}

1-Tobacco: Have you ever used any tobacco products? (As s/he may quit yesterday)
How many packs a day? For how long have you been smoking?
Have you tried to quit?

2- Illicit drugs: Have you ever tried any recreational drugs? What is the drug?
How do you take it? And when was the last dose?

3-Alcohol: Do you drink any alcoholic beverages? What type?

How much do you drink ?(Ask it even if s/he said occasionally)
(If a man consumes > 2 drinks/day or a woman > 1 drink/day ) ask then
(Alcohol related case)
Have you ever tried to Cut down on drinking?
Do you feel Annoyed by other people comments about your drinking behavior?
Do you ever feel Guilt about drinking?
Have you ever had to drink alcohol in the Early morning?(1st Q to be asked –
if +ve: Don’t ask all the Questions / If –ve :Ask the rest of the Questions.
If s/he said no to all so, s/he is NOT alcoholic, SO maybe drink occasionally
4-Work: what do you do for living?

5-Travel: Have you traveled outside the Country recently? When and Where?
Have you gone camping lately? Do you know if you got bitten by an insect?

5-Exercise : Do you exercise regularly? (In general checkup-DM-HTN-In F/U-

6-Living: Whom do you live with?-Are you safe at home?

Can you tell me about your living conditions?(esp in abuse or elderly)

6-Stress : Are you under any kind of stress ?

7- Support System: Do you have any support system around you when you are upset?
1 - Ask about thyroid symptoms in:, depression, amenorrhea, weight changes
2 - Abdominal pain: Ask about black or tarry stools / Ask about relation of the pain with food intake.
3 - Abuse: Ask about emergency plan, if family and/or friends know about what's going on /support system
4 - Bruise, depression: Ask about abuse
5 - Chronic cough: Ask about HIV, TB, ACE inhibitors use
6- Any Cough: Must ask about Travel/TB/Pets
7 - CNS case: Ask about previous stroke, migraine, seizures, syphilis
8 - Dizziness: Ask about tendency to fall towards left or right /ear symptoms/neuro& cardiac symptoms
9 - Depression: Ask about guns and pills at home, auditory hallucinations
10 - Forgetfulness: Ask about ADLs, IADLs, social support, head trauma, depression, syphilis
11 - Jaundice: Ask about urine and stools color- weight changes
12 - Hearing loss: Ask about exposure to loud noises
13 - If you have to say "I don't know", say "I don't know yet!" / DO NOT SAY trauma...say accident
14 - Insomnia: Ask if the problem is falling asleep, staying asleep or waking from sleep; frequent movements of legs, hot
flashes; order sleep diary for 2 weeks
15 - Menopause: Ask about mood swings, Fx of breast and uterine cancer; counsel about weight bearing exercises.
16 - Palpitations, insomnia: Ask about caffeine intake
18 - Rash: Ask about sun exposure, ticks, mosquitoes bites ,allergic reactions, joint pain, recent travel or camping
19 - Pain in hand: Ask about repetitive movements, job, such as operating a keyboard
20 - Obesity: Ask about joint pain, hypercholesterolemia, BP
21 - SOB: Ask about wheezing, on lying flat, how many pillows, PND
22 - Swelling: Ask about diurnal variation
23 - Psychiatric cases: Always check social support, offer social worker help
24 - Thyroid problem: Ask about change in voice, hair, period, bowel, temp tolerance
25 - Trauma in elderly: Ask about abuse
26 - Vomiting: Ask about fever, headache, if it is projectile; if yes for any, do a fundoscopy (Suspect brain tumor)
27-PREGNANCY : Regardless of the menstrual Hx , suspect it in a woman of childbearing age who has unexplained weight gain.
28- In a back pain or musculoskeletal pain We should start the HPI with the age & the occupation of the pt.
29-Remember Passing out = spell = blackout = LOC = syncope
31-Remember in any epigastric pain ask about: jaundice, black stools, blood on the stools, postpandrial fullness( bloating of
the belly), or early satiety.
32-In any case of “ Dark Urine” , remember to ask: Have you eaten any food that could cause this change in color, such as
berries, colored candy, or beets?/ Chest symptoms (For pulmonary renal syndrome)
33-Remember to ask in any case of dark stool: Have you taken any iron supplements, beets, or peptobismol (Antidiarrheal)?
35-In any fever: Ask about night sweats & chills / recent ill contacts / exposure to anyone with TB
36-In any accidents: Ask about Head trauma& LOC.
37-In any respiratory infection : Ask about chest Qs + HEENT Qs(for URI)
38-In any trauma case(MVA/Sexual assault/Fight/Falling from above):Same history-Scan from above downwards focusing on
head trauma – pain anywhere (ask always about PMI)-
Two important features of CIS are " Paraphrasing " and "Summarizing" and also showing
sympathy when appropriate.
*) Paraphrasing : After asking the patient about the Chief complaint in detail repeat what he
told to him; this shows that you are listening to the SP. Do this thing at least 2 times in your
history. Paraphrasing concentrates on only a particular symptom unlike Summarizing which
gives overview of the whole case.
*) Summarize after the history in brief . Do the counseling bit here if you had not done that
before. Now proceed to the physical

* At least 3 PARAPHRASES in history / Use the patient’s NAME at least 3 times.

* You should also use OPEN-ENDED QUESTIONS at least 3 times.
* If the final bell rings & you haven’t finished the encounter, immediately excuse yourself
telling the patient “Sorry Mrs. XYZ, I have to go now and come back to you as soon as
possible”. It’s totally acceptable & will save you from a very awkward end to the encounter.

Empathy and reassurance:

*I (Understand-realize-can see-can imagine) that it must be so difficult for you
*That (seems-looks) like very uncomfortable for you……
*Imp Words: Painful/Hard/Difficult/Annoying/Uncomfortable/Distressful=distressing
/ upsetting /hurtful /bothering

Challenging Questions:
*I understand your concern (I can understand what you are going through now),but it’s early
for me to make a diagnosis (right now / at this point)….
There are many causes of your symptom..and(Pt’s suspicion) could be a possibility.(optional)
*I need to run some blood tests and take some pictures of your …, once I get the results, we
will meet again to discuss your diagnosis &the management plans. OR

I understand your concern Mr., but I’m in the middle of my assessment. I need to ask you
some more questions and do a physical exam then we will order some tests. After that, I will
be able to tell you exactly what you have. Does this address your concern?

*If he asked after the closure, tell him (Let’s wait for the lab results, once I get them…..etc).

As far as (The pain medication/note to your letter/…etc) , I’d like to give it to you ,
However I do need to ask you some questions & do a physical exam so we can understand
what’s going on before I give you this ….. is that okay? OR

In order to treat you appropriately, I’ve to ask you some questions& do a PE, is that okay?

Money issues: Let our social workers help you with the cost issues.”If necessary, I can write
a note to your insurance company indicating the importance of these tests.”

Child alone: “I understand your concern about your child, but right now staying in the
hospital is in your best interest. One of our social workers will arrange for your child care.”

STDs: The important step is to have you both evaluated & treated

Impotence+Aging: We have medications that may improve your sexual function.”

Herbal ttt: their safety and efficacy may not always be clear-cut. Let me know the name of
the herbal medicine and I will check its treatment effect for this disease.”

Tumour(Benign/malignant): We really don’t know until we take a biopsy and get a

pathology report on it.

Surgey or Not: “I will try to manage your problem medically, but if that doesn’t work, you
may need surgery. We’ll see how things go and then try to make that decision together in the

Getting better: This depends on the underlying problem& its prognosis, but we have a lot to
offer in terms of controlling the symptoms and improving your quality of life.”
We will do our best and hope for the best.

A patient with COPD asks, “Will I get better if I stop smoking?”

“Most patients will experience a gradual improvement in their symptoms. But It may take a while
before you notice the benefits of quitting smoking. In the long term, it will significantly
decrease your risk of lung cancer in the future.”

Angry Pt.: I am sorry that you had to wait so long. The clinic was so busy today. But I’m
here now, for you and your concerns, I apologize again, How can I help you today? ”

-If patient start crying “ sit down for a while, wait for 3-4 seconds “ hold his / her shoulder
by your hand for a second “ express empathy by saying {This must be a very difficult time
for you. Ms…Would you like to share with me what happened ?}
*And also offer tissue paper (never lose a sight of the human connection)

-If patient starts talking irrelevantly Excuse me for interrupting you, Mr…I know these
concerns have really been bothering you. However, right now I wanna focus completely on

“Do you think they are going to give me the job?”

Employers routinely request medical examinations to ensure that the employees are fit for
the job, & don’t have any medical conditions that are hazardous to others in the work
I will ask you few questions and perform a physical examination, and on the basis of what I
find, I may or may not order further tests. Hopefully everything will be fine.”

“Will I ever be able to sleep well again, doctor?”

“I think so, but first we need to run some tests to rule out any underlying medical problems. In the
meantime, I would recommend you to change your lifestyle:
*If you drink lots of caffeine: Try to cut down on drinking coffee
*You should get used to go to bed early and at a fixed time
*You might try listening to soft music before you go to sleep.”

“Doctor, do you think I will be able to move my arm again like before?”
“I hope so, but first we need to find out exactly what is causing your problem.”
“We had not planned to have a baby so soon after marriage.What should I do, doc?
“I understand your anxiety about this unplanned pregnancy. I suggest that our social worker
can help you& your husband dealing with this issue.
I wanna assure you that I am here to support whatever the decision you take.

Do you think I am going to die?

“I understand your concern but I need to know more about your condition by asking some more
questions and do a physical exam to know if your pain is life threatening.”
I wanna assure you that we will be monitoring you very closely from now on, and you have
made the right call by coming here today and I’m here to assist you. You are in safe hands.

If the pt got bothered from your questions:

I know these questions may not seem relevant to what you are experiencing but sometimes
they are related in a different way. So, please bear with me for a few minutes. I’m here to
help you.

A diabetic pt asking : “Will I lose my feet, doctor?”

If we keep your blood sugar and cholesterol levels well controlled plus caring measures of
your feet, we can keep it healthy and you will not lose your feet.

Questions about medical Facts:

“My mother/brother had breast/colon cancer. What is the possibility that I will
have breast/colon cancer, too?”
“You maybe at risk, but it doesn’t mean that you will get it. There are other risk factors that
need to be considered, and regular screening tests will be very important.” OR

I need to get more information about your personal and family history to determine your
level of risk.”(Optional)

A 55-year-old man says, “I had a colonoscopy six years ago, and they removed a
polyp. Do you think that I have to repeat the colonoscopy?”
“Yes, it should be repeated. We need to screen for more polyps, and in this way we hope to
prevent the development of colon cancer.”

An educated 58-year-old woman asks, “I read in a scientific journal that hormonal

replacement therapy causes breast cancer. What do you think of that, doctor?”
“It appears to be true. Studies show a slight increase in the risk of developing breast cancer
after four years of HRT. The current recommendations are to use hormonal replacement
therapy only for the relief of hot flashes, and only for a limited period of time.”

“Can I get pregnant even though my tubes are tied?”

“There is no single contraceptive method that is 100% effective. Your chance of getting
pregnant is <1%, but it is a real risk.”

A woman who is in her 1st trimester of pregnancy with vaginal bleeding asks, “Do
you think I am losing my pregnancy?”
“It’s a probability but I wanna assure you that most women who have bleeding carry the
pregnancy to term without problems. Also we will do some imaging studies to be sure that
everything is okay
“Obesity runs in my family. Do you think that this is why I am overweight?”
“Genes play an important role in obesity, but lifestyle, diet, and daily habits are also major factors
influencing weight. We can use these factors to help you lose weight.”

“I am drinking a lot of water, doctor. What do you think the reason is?”
“This may simply be due to dehydration, or it may be a sign of a disease such as diabetes.
We need to do some tests to determine the cause.”

HIV pt: What is CD count? ,how often will i be tested? How long before i get sick?
who am I obligated to tell?
*Cd4 cells are the infection fighting cells of our body.
*You should ideally have the test every 3-6 months.
*Mr.…, it’s hard to predict exactly when you will be sick. But I want to reassure you that
there are medications to fight HIV and you are not alone, so you can call our office anytime if
you have any questions.
*Also I suggest you discuss your diagnosis with you sexual partners and convince them to
seek medical advice.

Pt needs a refill:
Based on the information you’ve given me and the PE, I do believe that you need a refill on
your medication and I’ll write you a prescription today. If you have any other symptoms or your
symptoms are not resolved, plz feel free to call our office.

“My father had a clot in his leg. What do you think I should do to make sure I don’t
get one too?”
There are several measures you can do:
1-Avoid immobilization for long periods of time—for example, while sitting at your computer
desk or on long-distance trips. Try to move in place and perhaps take a short walk.
2-If you are on OCP, I would strongly recommend that you stop taking them, as they are
known to precipitate clotting
3-Exercise regularly and manage your diet.”

“I want to go back to smoking because I believe that I have started gaining weight
since I quit.”
*I understand your concern, but it’s clear that the health consequences of smoking far outweigh
those associated with weight gain.
*We also need to exclude other causes of your weight gain by running some blood tests.
*We have an expert dietician here that can help you & give you the proper advice
Specific Situations:
Smoking :
*Ms. Ray, as a concerned physician, I strongly recommend you to quit smoking as it’s a
major cause of cancer plus heart & lung problems. Are you interested in quitting/Do you have
any plans to quit?
*We have many tools & resources here in our institution to help you do that, my nurse will
bring you a pamphlet.
*(Optional) Also You can use Nicotine patches or Gum to help reduce those withdrawal
symptoms. I will give you their phone numbers. "

*If said no:

I understand that you aren’t ready to quit smoking yet, but I want to assure you that
whenever you are ready, I will be more than happy to assist you

Alcoholism / Alcoholic PatientsIf yes for eye opener or any other 2 questions:
*Mr.….,I am concerned about your drinking habits, Excess alcohol causes Liver& pancreatic
disease and is known also to raise your risk of high blood pressure, strokes.
(In females only) It can cause birth defects if consumed during pregnancy
Are you interested in cutting down or quitting?
*If you decide to cut down or quit alcohol, we have a professional team that can help you
deal with it better. Feel free to contact them anytime.

*For Cutting down:

- Limit intake to one drink per day ( for women) or two per day (for men).
- Eating food while drinking will slow alcohol absorption.
- Avoid drinking before or when driving, or whenever it puts you or others at risk.

*If said no:

In the event that you decide to cut down or stop drinking , you can call our office anytime ,
we have a lot of wonderful programs that can assist you with this , Okay?

Recreational drugs:
Mr….., As far as Cocaine , marijuana , Both of them are extremely dangerous for your health,
, and they are not good for your nervous system as well. Are you interested in stopping these
stuff. We have wonderful …etc

N.B: If the pt answers yes to all of the three questions …To save time, tell him/her:
As far as the cigarettes, alcohol and marijuana, All of these three things are very bad for you
health,& open the gates for many diseases . So are you interested in changing these habits.
we have a program for each that can assist you so much..would be interested in a pamphlet?

*Mr…., we have a lot of evidences that weight reduction alone, could reduce your symptoms by
50% or even more".
*We have an expert dietician here in our clinic, who can give you information about the healthy
diet and how to develop healthy-eating habits
*So if you are interested, I can refer you to him/her, and I believe s/he will help us a lot to treat
your condition
* You can Walk 20 minutes , 3 times/week to start
Mr. XYZ - First of all, you should understand the disease and know how to manage it to keep yourself
healthy and reduce complications. These are some essential rules to know:
1. Follow regular exercise and diet instructions that will be provided to you (low salt , high fiber ,
low calories)
2- Learn how to recognize the symptoms of low sugar levels, such as confusion, disorientation, or
fainting. You should always carry glucose tablets or juices as an “emergency kit.”
3. Diabetic patients are vulnerable to injury-induced ulcers on the foot, so make a habit of using soft
footwear whenever you walk - indoors or outdoors. Keep your feet dry & clean
4. Be regular in blood-sugar monitoring 2X/DAY so that dose adjustments can be done on time. As
Persistently high blood sugar can cause damage to your eyes, kidneys, and nerves.
5.Fortunately, we have a diabetes counselor who may be able to help you. Are you interested in
meeting hi m?

Hypertension Counseling:
*Mr…., High BP could cause stroke, affect the functioning of the heart, and even the kidneys.
*There are some simple rules : regular exercise, reduction of weight (if the patient appears
overweight), and limiting salt in your food could help in keeping your hypertension in check.
*I strongly advise you to do regular check-ups to help control your blood pressure.
*However, there may be some patients with treatable causes - we need to order a few tests to
see if we can detect those in you."

HIV Counseling:
*The biggest danger in HIV may not be the HIV itself – but the diseases that can occur more
easily due to reduced body resistance.
*Thus, periodic examinations and follow-ups are important. We have a professional support
group here which can help you with that

Safe-Sex Counseling points:

1. Ms…., I understand that you may not like to use condoms, but I’m concerned as you are
putting yourself at risk for STDs like HIV, gonorrohea, hepatitis and increase the risk of
Cervical Cancer, unwanted pregnancies.
2. I would strongly recommend you to use condoms regularly. (If patient or partner is on OCPs you
can add)Also, I would like to tell you that Oral Contraceptive pills don’t protect against
sexually transmitted disease.
3. Watch for symptoms of STDs, such as unusual discharge, sores, redness, or growths in your
and your partner's genital area, or pain while urinating.
4.After your consent, we can do a blood test for HIV
5. Add counseling about PAP smear depending on the Patients age !

Lab-Result (Trichomonas):
1. Ms…., You and your partner need treatment.
2. While you are on Metronidazole therapy - alcohol is to be avoided, As it will cause unpleasing
effects like nausea and vomitting (Disulfiram like reaction)
3. Abstinence from sexual intercourse until therapy is complete

Counseling for Heel Pain:

1. Mr…., Use soft-heeled or soft-padded footwear.
2. Refrain from long standing positions or long walking activities
3. If the prescribed pain medications do not work, plz give me a call
Counseling a Non-Compliant Seizure Patient who wants to drive:
1. Mr…., Driving is dangerous not only to you but also to others on the road if you have any
2-Also swimming should be supervised because of the riks of accidents,

Counseling a reluctant patient (Not speaking)

*You look quiet and sad to me. I know it could be a very tough time for you, However in
order to help you , I need you to tell me more about your problem. if you do so, I will be able
to determine what is wrong with you and help you feel better.

Counseling domestic violence:

* Ms Smith , From what you said I understand that sometimes, You feel unsafe at your own
home. It sounds very frustrating. I am glad that you came here to seek help.
*And if you ever feel unsafe or hurt, you should seek attention from the appropriate
authorities. I will get you the telephone numbers and their contact information
*Remember, it’s not your fault, you did nothing wrong and you don’t deserve to be abused.
*And if you ever need someone to talk with, please don’t hesitate to call our office.
*(Optional according if there are children or not ) Although everything we discuss is
confidential, I must involve the child service if I believe that your children are at risk.

Counseling depressed pts:

*Mr Smith , I know that dealing with depression can be very difficult and can cause physical
and emotional stress.
* We have here wonderful groups and professional counselors who can help you through this
difficult time. I just want you to know that you are not alone. Would you like to talk to
counselor? Or join a support group?
*Also, I want you to promise me that if you feel like hurting yourself, you will call someone
who can help you or go immediately to an emergency department.

*Ms. XYZ, I wanna ask your permission to speak with one of your family members about
your social support and safety at home. Is it ok?.
*We have an excellent social worker that can help you in managing your daily activities and
future living plans in case you need it.
*(If Abused),I’m really concerned about your safety, we have here nice shelters for the
senior citizens that can help you a lot

Loss of consciousness=passing out

*Ms xyz, At this time I strongly recommend you not to drive again until we find out what caused
your LOC I understand that this might be inconvenient to you but it’s mainly for your safety.
*I assure you that I will do everything I can to get to the bottom of your problem, so that
you can resume your regular daily activities

*Mr. Smith, asthma is a chronic disease that needs long term therapy. Most common cause of
recurrence of asthma symptoms is interruption of controller medications.
*The inhaled medication (name it if the patient told you the name) is a steroid that
suppresses swelling of your airways and prevents symptoms.
*You should take it every day without missing a single dose.
*I am glad to see that you are regular with your checkups and I want to see you again in
about 3 months for another checkup
*Ms…,As you know, it’s a problem of aging and related to wear& tear of the joints. The pillars
of management are regular exercise, weight reduction& regular pain killer to relieve pain.
*We may also try heat & cold therapies or local massage with oils and anti-inflammatory
* surgery or joint replacement only in advanced cases
Enuresis (Bed wetting) Counseling :
*Ms. Cole, kids with bedwetting usually undergo natural healing with age, but this problem needs
tenderness. Punishing your child could worsen it – You should rather praise and reward him if he
stays dry while sleeping.
*I would advise you to monitor your child's drinking habits before going to bed and encourage
the child to go to bathroom before going to bed.
*We also need to do some tests to figure out any underlying causes.

Constipation in Children:
Ms ….., There are many things you can do to help your child:
1- Start by increasing the fluids, fruits and vegetables and decrease the amount of candy or
sugar in his /her diet
2- Do make him sit on the toilet at least 10 minutes at the same time each day, especially after meal.
3- Begin rewarding your child for just sitting on the toilet by stars on chart, trip to movie
theatre or to the park. Don’t use food as a reward.

Emergency in Children(Noisy breathing)

1- Ms…I strongly suggest that you call 911 immediately and bring her/him to the medical
center as your children condition could be serious.
2- If you observe significant respiratory compromise or choking, please perform the Heimlich
maneuver by thrusting your child’s tummy with sudden pressure.
3- I hope you understood what we have discussed today.(essential)

Picky Eater:
1-Ms Smith, I think it’s an isolated problem in this age group, children are moody in this age
2-First of all, I’d suggest you to strictly follow a set schedule and offer him/her a variety of food at the meal
time. Discourage high caloric food in between the meals
3-The next important thing is the environment at mealtime. It should be pleasant. Avoid any arguments or
watching TV

Jaundiced Child:
* Ms. Xxxx, I would recommend you to Keep him/her well hydrated. Nurse your baby every 1 to 2
hours during the day.
*Don't let your baby sleep more than 4 hours at night without feeding.
*If your baby is 5 days or older AND has less than 3 stools/day, carefully insert the tip of lubricated
thermometer into his/her anus and gently move it from side to side a few times to stimulate
a stool which will carry bilirubin out of the body. Do this once or twice per day until jaundice
improves or stool frequency becomes normal.

ORS Counseling in dehydration: Enquire if the woman knows about Oral Rehydration
Solution and whether she has Pedialyte at home - if Yes, she can start having her baby sip on
it. If she does not, you can suggest a quick home-made solution like this, till bring him in
A. Water - 4 Cups B. Salt - 1 Teaspoon C. Sugar - 8 Teaspoons

*Hope you understood whatever we discussed today? (In All Cases)

Psychiatric History
Onset: “For how long have you been feeling (This way) unhappy/sad/anxious/confused?”
Course: Do you have any idea why do you feel this way? (Mostly not answering)
I know it could be hard for you but “Would you like to share with me what made you feel this
way?” I’m here to help you

“FACE SLIPS” Mnemonics:

F: Feelings of guilt, anger. {Do you feel guilty about anything?}
A: Abuse --- {Have you ever been abused?}
Appetite (diet, weight) ---- {How is your appetite? Then has your weight changed recently?}
C: Concentration levels. {Do you have difficult time concentrating?}
E: Energy levels in daily activities. {Can you still perform your daily activities?}

S: Sleep disturbances {Do you have any changes in your sleeping habits?}
L: Life stress-{Have you had any recent stressful events?}/How is your libido?
Hallucinations: {Do you hear or see things that others don’t?}
I: Interest? Hobies? {Have you lost your interest in your social activities and relationships?}
P: Psychomotor symptoms---- {Do you feel restless?}
S: Suicidal thoughts, any plans? {“Have you ever thought about hurting yourself or ending
your life?”-Do you have any plans? Do you have guns at home?}

Then Past Medical History. (PAM HS FOSS)

Onset: Age of first symptom: when did you first notice something is happening to you?
Did they begin suddenly or gradually? Were you upset about that?

Negative symptoms
Blunted affect: observe nonverbal signs of emotion-body movements,
Decreased speech: Do you have difficulty with your speech?
Social withdrawal, decreased motivation: How is your energy level lately? How is your relation with
your family/friends?
Cognitive symptom: Do you have racing thoughts?

Positive symptoms:
Delusions: “Do you hold beliefs about yourself or the world that other people find it odd?”
Hallucinations: “Have you ever seen or heard things that others can’t see or hear?” what are
these? What are they telling you?
Disorganized thoughts, disorganized or catatonic behavior)
Do you ever feel that people want to harm or control you?
Do you ever feel that TV is talking to you or about your thoughts?
Do you feel restless and agitated?

Organic causes of psychosis(DD)

Do you have any hearing/vision problems?
Brain tumor – Infection ”Encephalitis” - drugs

Insight: “Would you like to join a support group or talk to a counselor?”(A must)
Then Past Medical History.(PAM HS FOSS)-mainly Fx of mental illness/(Social History)
Living conditions/Stress/Support system
In Any Psychiatric case : Always ask about Abuse & Thyroid disease
Dmentia (Memory problems)
 Do you have any difficulty with your daily activities like (bathing-feeding yourself-
getting dressed-using the restroom)
 Do you need any help {taking your medications/using the telephone/doing the
shopping/preparing food/doing housekeeping /doing bills = accounting?}
 How about transportation, are you able to drive?
 Have you ever lost control of your urine or bowel?
Domestic Abuse (Women – Elderly)
1-Can you tell me about your living conditions?
2- Are you safe at home?
3- Does anyone in your personal life treat you badly?
4- Do you know why s/he is doing that?
5- Has it ever happened before? If yes - How many times?
6- Do you have a plan of what to do if you feel threatened?
7- Do you have guns at home?
8- So, How is your mood? (Depression Qs is mandatory)

I notice you have a number of bruises. Can you tell me more about them?
It does not look like being caused from a fall. Did someone do this to you?" If said no and
anxious ---tell her,

"I understand that you may be uncomfortable to discuss about this but as your concerned
physician, your safety and your health are my first priority. Would you like to share it with

*Children--" How many children do u have? How old are they?

How is their relationship with your husband? Has he ever hit or threatened them?
Hello Ms…., Hi, My name is Dr… I’m the physician in the office today. It’s nice to speak with
you…Okay Ms…How Can I help you today? -----Chief Complaint

Ask about Name / Age ? Then sympathy(I’m really sorry to hear about your situation, I
will do everything I can to help you today.
Full analysis of CC: Can you plz (explain to me what happened /tell me more about that)?
ROS: now I’m gonna ask you some questions about his/her general health, is it okay?

General: (Fever-Seizure-Rash)
 Has s/he had any recent infection (mainly respiratory in children)?
 Was s/he feverish? Have you taken his/her Temp.?How high was it? Did you take it
orally or rectally? Is s/he shaking at all?
 Does s/he have any rash anywhere? If yes, when did it start? Can you describe it?
 How does s/he look? - Is s/he tired or playful? Then is s/he crying a lot? v.v.v Imp Q
 How is his/her sleeping? If Not good, does s/he snore at night (esp. in Bed wetting)
 Impact on the patient& Family (Mostly in older cases > 6yrs),How does this affect you?

Head: Have you noticed any stiffness when s/he moves his/her head?
Neck: Any swelling in his neck?
Eye: Have you noticed any redness or teary eyes?
Ear: Do you know if s/he is pulling at his ear? How often? Any discharge?
Nose: Does s/he have a runny nose?
Throat: Does s/he have difficult time swallowing?

Does s/he have any difficulty breathing -Is s/he breathing fast? If yes, Is s/he turned blue?
Is s/he coughing? If Yes, Anything comes out from his mouth? then analyze it

Is s/he eating well? Did s/he throw up?
Any changes with bowel motion (Stool caliber- frequency- color-blood & consistency) –
Have you noticed any weight changes with him/her? Then Is he following any Particular diet?
Does s/he scream or cry during bowel movements?-or Any belly pain was noticed?

Has s/he ever had any changes with his/her urination? (Urine frequency-color-blood)
Does s/he cry when s/he urinates?
How many diapers are you changing per day?

Musculoskeletal: Do you know if s/he has any weakness of his limbs?

Neurological: Has s/he ever had any type of shaking movements?

Past History {PAM HS FS}
P: 1-Has s/he ever had similar episodes in the past? Followed By
2-Has s/he ever been sick before?
A: “Does your child have any allergies?(medication-food-Pets)
M: Is your child taking any prescribed medications? Or any over the counter medications”
H: Has your child ever been hospitalized?
S: Has your child done any surgeries before?
F: Does anyone in your family have similar symptoms or problems with(e.g, Kidney disease)?
S: Have you noticed any ticks or insect bites on his body?
I’d like to ask you some questions about the pregnancy & his/her birth is it okay?
Prenatal History:
 Did you have any prenatal care? Did you take multivitamins?
 Did you have any complications during your pregnancy?
 Did you smoke, drink, or use recreational drugs during your pregnancy?(3 separate

Natal (Birth) History:

 How was the labor? Was it normal vaginal delivery?
 Was s/he full term?
 How much did s/he weigh?

Neonatal History:
 When did your child have his first bowel movement?(Very important)
 When s/he was born,
-Did s/he have any discoloration of his/her skin ”cyanosis-jaundice”?
-Did s/he take any medications?
 How long did you stay in the hospital after delivery?

Feeding History:
 After birth, did you breast-feed your child? And for how long? Or bottle fed
 Can you describe to me his/her typical diet?
 Is s/he taking any vitamins? What kind?
 When did your child start eating solid food?
 How many diapers are you changing per day ?(<6 needs evaluation)

 How about his/her development? Or is s/he growing well?
 When did your child start smiling-2m/sit up by himself-6m/walking-1yr?(Optional)

Routine care:
 Are your child’s immunizations up to date?
 Does s/he do checkups? When was the last one? Was it normal? With whom does
s/he follow up?

S: School/Preschool ”Daycare is after 6 wks”.

 Does your child go to a daycare or preschool?
 Has he been around anyone who is sick either at home or the daycare?
 How about his/her academic progress at school?

S: Social History:
 Who does s/he live with? What kind of house do you live in?
 Has your family moved recently?
 Are there any stressful events or family problems that s/he is passing through?
Does s/he have any siblings? If yes, is s/he getting along with his siblings and friends?
How much time do you spend with him/her?
( Any pets / Any family member smokes )at home?-Mainly in chest cases

Well, thank you Ms. Smith, for answering my questions.

Okay, let me summarize what you have just told me. You said …….Is that right/correct?
Would u like to add anything else?

*Based on the information you’ve given me, I think your child might have ….. , however, we
also need to exclude some other possibilities , such as…..

*For that reason, I would like to examine him/her and order some tests before I make my
final diagnosis.

*Is it possible to bring him in today? Yes…. That would be great.

Do you have any problems with transportation? If No, that’s it.

If Yes,OK, Ms. Smith, in that case, we have social worker here who can help you with your
transportation. After we are done on the phone, I will transfer your call to him; he will help
you with this issue. Does this sound good to you? (Absolutely)

*Do you have any other questions or concerns for me? If yes, answer it
If NO, Please, do not hesitate to call our office if you have any questions.
I’m looking forward to meeting you again and Have a good day.bye bye

Challenging questions & Counseling situations:

“Can you explain to me exactly what is going on with my child and what can be
done for it?” or Can you give me something for her?
*I understand your concern Ms, but
It is hard for me to give you an accurate answer (right now/over the phone). OR
Right now, it’s too early for me to know what’s is going on with your child so,

*I would like you to bring your baby here so, I can examine him/her and perhaps run some
tests. After that, I will be able to give you a more accurate assessment of his/her condition.

Determine if it’s an emergency:

like baby not waking up, no urine passed since a long time, incessant diarrhea etc. –Tell her,
{Its urgent to get the baby to the hospital immediately as it could be an emergency}
If the mom has no time / no car / no one else to get the kid - ask her to call 911!!

N.B: If s/he goes to daycare:

I think s/he shouldn’t go to the daycare until his symptoms are resolved .Because s/he may
have an infection that could be transmitted to other children or he may have got that
infection from another child.
Before the Physical Exam Show Sympathy then Summarize the history
Mr./Ms…..,I’m very sorry to hear about what you are{ experiencing ”going through” }
Let’s summarize up, You said, you have … and …, also, you …, Is that right/correct?

(Physical Examination)=3-4 systems are so enough

1- Based on these information, I need to do a physical exam on you, is that okay?
If Said NO: To understand your problem correctly, I need to do a PE, I’ll be as quick as
possible. I’m here to help you.
2- Can you plz excuse me while I wash my hands.
3- While you are washing your hands,ask the SP about (Keep Him Engaged)
 So Mr/Ms last name, What do you do for living?
 So Mr/Ms last name , “Is there anything else you would like to bring up? (Promote
challenging questions)
Answer: Whatever it turns out to be, I wanna assure you that I will do everything possible
to make you feel better.
Patient In the setting position:
A. Examine Head(eyes, oral cavity) & Neck(thyroid & glands)lymph nodes palpation
B. Then Examine Thyroid From The Back.
C. Now I need To Examine Your Chest & Heart. May I Untie your gown. Finish off and tell him
,” Let me tie back your gown.” Thank You.
D. Examine The legs for swellings and fingers for any signs of any underlying disease.
E. If required, Do The Neurological examination

Patient Is Lying down/back(Help during the process& pull the leg support out)
When you make the patient lie down ask him: Are you comfortable?
A. Examine neck for JVP& carotid bruit.
B. If Required, Do the abdominal examination (Don’t make the pt. lies twice).

When To Do HEENT & Neck exam (Headache-Head trauma)/(Ocular problems ”visual

disturbance – eye pain)/(Ear problems “Tinnitus-vertigo-hearing loss)/ (Nasal problems
“rhinorrhes-epistaxis-sinus pain)/(Pharyngitis-voice changes-jaw pain)- Fatigue
*Only perform the relevant components of the HEENT and Neck/Thyroid exams depending on your DD

1. HEENT exam:
1. Inspect the head for signs of trauma and scars.(Now I’m looking at your head for any
skin changes , swelling, or scars
2. Palpate
A-the head :for tenderness or abnormalities.( “I’m gonna feel around your head. Please let me
know if you have any discomfort”)- Thank you
B-The sinuses:{Frontal-Maxillary ”One side at a time- with your thumbs”}Now I’m gonna press
on your forehead and sinuses ,plz let me know if it hurts)–do it in any chest case

Lymph nodes: Now I’m checking your neck for any lumps. Followed By:
Thyroid: * I’m checking your thyroid gland which sets in the front of your neck , I need you to
swallow for me ,Plz? Do you need some water? Okay let me get it for you? Thank you
*I’m gonna press lightly on your thyroid gland to check for any enlargement or abnormalities
, Can you swallow again for me plz , Thank you
Eyes: .( “I need to examine your eyes now.”)
1. Inspect the sclerae and conjunctivae for Now I’m looking at your eyes for any
color and irritation. abnormalities –plz look up, down for me.
Thank you
2. Check the extraocular movements of the Can you follow my index finger without
eyes. moving your head. Thank you
3. Check visual acuity with the Snellen eye Could you plz cover your Rt.eye and tell me
chart. how many fingers do you see? Then can you
cover the other eye plz. Thank You.
4.Check the pupils for symmetry and reactivity {“I need to look in your eyes, Can you plz
to light.(light reflex-accommodation) look straight at my ears? Thank you
5. Perform a funduscopic exam. Now I need to take a deeper look in your
eyes ,Thank you

1. Conduct an external ear inspection for Now I’m looking to your ears for any
discharge, skin changes, or masses. discharge, skin changes or masses
2. Palpate the external ear for pain (otitis Now,I’ll pull up & down at your ear gently, just
externa) let me know if you have any pain. Thank you
3.Examine the ear canal and the Now I need to check your ears with this device
tympanic membrane using an otoscope. for any abnormalities. Thank you
4.Whisper test Can you hear my fingers from this side? how
about the other side?
5.Rinne test This tuning fork is gonna ring and I’m gonna
(Normal is AC>BC) positive Rinne put it at the back and in front of your ear, let
(CHL is AC<BC) negative Rinne me know when you hear it and when you
(SNHL is AC>BC) positive Rinne don’t,…. Can you hear that?
6.Weber test(ONLY done in UNILATERAL Now I’m gonna put it on top of your head? tell
hearing loss ) as normally shows no me which side you hear it louder or they are
lateralization(same when pt has bilateral the same.
Hearing loss)

Nose(Use light source without a cone)

I need to look into your nose. Can you plz look up for me

Now I need to check your mouth and your throat With this light”:
Plz open your mouth wide. Can you stick your tongue out and say AHH. Thank you

Examine Chest & Heart Simultaneously At One Setting.(I need to examine your heart
and lungs, May I untie your gown? Thank You.

2- Pulmonary exam(Full examination in chest case) otherwise auscultate only

Posterior Chest(Percussion/Auscultation/TVF) I need to check your lungs, Thank you.
Anterior chest(Inspection/Palpation):I need to lower your gown , plz
1-Inspection:Now I’m looking at your chest for any abnormalities. It looks normal
2-Palpation:I need to press on your chest, if you have any pain or discomfort, plz let me know
3-Percussion:Now I’m gonna tap gently on your chest
4-Auscultation:I need to listen to your lungs ,Can you please take a deep breath through your
mouth? again,again,again,one more time(4 times only).In the 2nd time ask pt, are you Okay?
5-TVF: Now I’m gonna put the side of my hand on your back, Plz say 99 , again(4 times) .
3-Cardiovascular exam:
(I’ll examine your hearts in a sitting and then lying down positions.)
Sitting Up:
1-Heart&Lung auscultation: “I need to listen to your heart and lungs plz. May I untie your gown.
Thank You. For women, tell her could you plz lift up your breast , Thank you.
2-Pulse:I need to check your pulse in your arms and legs(Radial –Dorsalis pedis).Thank you
3-Leg edema:I am gonna examine your legs for any swelling. Is that okay with you? Thank you

Lying backNever ever forget to pull out the leg extension (You can do this with
the abdominal examination if there is any , related to the case)
Could you lie back plz, Let me pull out leg extension to make you more comfortable.
1- JVD: plz look to the left. I need to take a look at your neck vessels for any visible pulsation
2- Carotid Bruit:“ “I need to listen to your neck vessels , Can you hold your breath for a
moment , please?” do it Bilateral. Thank you
4. Abdominal exam: I need to examine your belly/stomach
1-Inspection: Let me take a look at your belly for any abnormalities. It looks normal.
2-Auscultation:Now I need to listen to your bowel sounds.
3-Palpation: I’ll press gently on your belly then I ‘ll press more deeper , Please let me know if
you have any discomfort. Thank you.
4- Percussion: I need to tap gently on your tummy. Thank you
5-Rebound tenderness: Now I need to press in, on your tummy, plz tell me if it hurts when I
press in or when I let go? (Do it on the opposite side of the painful side).Thank you.
6- Murphy sign: I’m gonna press deeply on this area, I need you to take a deep breath& tell me
if you have any pain
7-CVA tenderness: I’m gonna tap on your back gently. Plz let me know if it hurts. Thank you.
5. Neurologic exam:
A.Mental status examination: Orientation, concentration, memory. Almost not done(Need time)
except in psychiatric case ”even it’s the only exam the you will do” 1 st to be done

1-Orientation: to PPT(Person – place- time)

“I would like to ask you some questions about yourself ,is that okay?”
 Can you tell me your full name?
 Do you know where are you now?
 What is today’s date?

2-Memory: (You Can ask it only and substitute the MMSE)--

“Now I would like to ask you some questions to check your memory.”
 “I will name three objects for you, and I want you to repeat them immediately,
okay? Apple, pen and chair.” (Tests immediate memory.)
“I will ask you to repeat the names of these three objects after a few minutes.”
 “Do you remember what you had for lunch yesterday?” (Tests recent
 “When did you get married?” (Tests distant memory.)
 “Now, can you repeat for me the names of the three objects that I mentioned
to you?” (Tests short-term memory.)

3-Concentration: Can you spell ‘world’ forward and backward.

B. Cranial nerves: Now I’d like to check your brain nerve functions, is it okay?
1. III, IV, VI: Extraocular movements. Plz follow my finger without moving your head. Thx
2. V: I’m going to touch your face lightly-do you feel my fingers ?
Can you bite down tight(Clench your teeth)? Thank you
3. VII: Can you raise your eye brows?./plz smile big and show me your teeth. Thank you
4. VIII: Can you hear my fingers (Finger rubbing)
5. XI: “can you Shrug your shoulders.”Thank you
6. XII: “Now plz Stick out your tongue, and move it from side to side.” great

C.Motor system: “I need to check the strength of your muscles in your arms& Legs, is that ok?”
1. Active motion: {All movements are against resistance}
Upper Limb-
*Hands: Can you plz squeeze my fingers tight? Thank you
*Shoulder& Arms: Can you plz (push out=abduction),(pull in=adduction);Thx
*wrists—Can you plz (move down=flexion),(move up=extension),(Move to both sides);Thx

Lower Limb–May I left your drape

*Thigh: Can you push up against my hand . Thank you
*Leg : Can you (“kick out”= Knee extension), (“pull in”= knee flexion). Thank you
*Ankles: Can you push up and down (against my hands)?. Thank you

D.Reflexes: “I am going to check the reflexes in your arms and legs is that okay?
UL: Biceps, brachioradialis,
LL: knee, Achilles
Babinski (If needed):Now I need to check the reflex at the bottom of your foot , it’s gonna feel
like a tickle .please bear with me for a while.

E.Sensory system: Now I’d like to test the sensations in your arms & your legs. is that okay?
This is Sharp and this is dull ,So plz close your eyes and tell me what you feel? Twice per
each limb then say is this like that in each limb?

Vibration, position sense(Only in Peripheral neuropathy. e.g DM)

*Vibration: I’ll placing this tuning fork on a part of your body (best is base of big toe), please
close your eyes. Did you feel the vibration? Thank you , you can open your eyes now.
*Position: Now I’ll be moving your big toe up &down. This is up, and this is down. Plz close
your eyes and tell me which direction I am moving your big toe.”

F.Cerebellum: any one of these is okay

*Finger-to-nose: Plz touch your nose with your index finger , then touch mine
*Heel-to-shin: can you take the heel of your foot and RUB It against your shin like that? and
the other one as well (demonstrate it if needed)
*Romberg sign: Can you stand up for me with your feet together, plz? Do you want any help?
Can you put your arms straight out with palms up, and close your eyes (demonstrate this)-
I’ll be standing beside you to support you. Thank you
*Gait: “Can you walk back& forth for a couple of steps, please?” You can sit down. Thank you

G.Meningeal signs: Now I’m gonna do a couple of tests to check for any irritation of the
membranes which covers your brain
*Kernig: I need to uncover your leg. I’m going to bend your knee and then straighten it. Plz
Tell me if it hurts. Thank you
*Brudzinski: I’m going to gently bring your neck forwards towards your chest and will stop if
there is pain , just relax while I do this . Thank you
6. Joint exam:(Check The Injured Joint 1st Then if you have time the adjacent ones)
1- Wrist pain:
Inspection: let me take a look at your wrist
Palpation: I know you have pain on this side, so let me start with the normal side first.
Now let me check the other side.
ROM(Passive: Now I’ll move your joints gently, plz let me know if you have any discomfort)
(Active: Can you move your hands up and down –to the left and to the right .Let me start
with the one that does not hurt so I can compare what’s normal and what is not )
Muscle Strength– Sensations–Reflexes : Same As Above
Pulses: I need to check your pulse in your arms , is that okay?
Special test for Carpal tunnel evaluation:
Tinnel test: I need to tap on your wrists. Let me start with the one that doesn’t hurt. Thank you
Phalen test: Can you do like this, Plz ,Let me know if it hurts. Thank you

2- Shoulder Pain:
Inspection: let me take a look at your shoulder
Palpation: I know you have pain on this side , so let me start with the normal side first. I need
to feel around your shoulder-start from the scapular blade if anything hurts, plz let me know.
-Now let me do the same on the other side. Thank you
ROM: Now I need to check on your shoulder movement. We will start with the normal one:
*Can you put hands behind your (head/back with your thumb up) like that.
*Can you stretch your arm out in front of you? Then do it all the way backwards , like that?
*Can you move your arm to the side all the way up to the top, like that?
Now with the other hand, go only as far as you can. Can you Do this – Do this. Thank you.
Muscle Strength(Shoulder shrug/flexion/Abduction against resistance)– Sensations–Reflexes : Same As Above
Pulses: I need to check your pulse in your arms/legs , is that okay?

3- Lower Back Pain:(After Listening to heart & lungs)

Inspection: let me have a look at your back & other joints
Palpation: I ‘m gonna feel around your back, if anything hurts let me know.(Use both thumbs)
ROM: Can you lean forward Plz, can you go to the side, can you twist to the Rt., to the Lt.
Thank You. If you have any difficulty with these let me know?
Please stand up for me, Can you bend forward & touch your toes, Thank You.
Muscle Strength – Sensations–Reflexes : Same As Above
Babinski :Now I need to check the reflex at your feet sole. Plz bear with me.
Straight leg test: Now I’d like to lift your leg straight up, is that cause you pain? I apologize for
the discomfort.
Gait : I need to see how you walk. Let me pull out the footstool. May I help you down? Please
walk to the other side of the room and back . I’ll be nearby. Thank You.
Pulses: I need to check your pulse in your arms/legs , is that okay?

4- knee pain:
Inspection: let me check your knees for any swelling or deformity. Okay.
Palpation: Now I’m gonna feel around your knee to see if there is any water , I know you have
pain on this side , so let me start with the normal side first. If there is any pain, let me know
ROM: Can you plz lie back for me. Can you bend your knees for me. How about the other one
can you go as far as you can..Thank you
Alright: Now I’m gonna move the normal one around, Do you feel any pain.
Anterior/Posterior drawer sign: can you bend your knee , Now I’m gonna push in & pull out./
Collateral strain: Now I need to push in & out From the side on your knee, Is there any pain?
Muscle Strength –Sensations- Reflexes-Pulse : Same As Above
5- Ankle painBetter to be done when pt is lying back
Inspection: Now I’d like to take a look at your ankle to compare both feet
Palpation: Now I need to press on your feet, Plz let me know if you have any pain
ROM: I’d like to move your foot in a couple of directions plz relax. Can you push it up& down-
move it in and out
Muscle Strength – Sensations – Reflexe(Achilis-Babiniski) : Same As Above
Pulses: I need to check your pulse in your feet

1) Briefly summarize
2) Brief explain your D/D
3) Explain Tests
4) Reserve management discussion (until we are sure what the problem is)
5) Avoid alarming the patient
6) Ask if the patient has any question
7) Thank the patient for coming
8) Reassure the patient that you will be careful and will do everything you can to help
9) Shake the pt's hand and say take care.
10) Leave the room

1- Thank you Mr.., for your kind co-operation, I’ve finished my examination,
2- According to the information you have given me and the physical exam, I am
considering a couple of possibilities), It could be …(probable diagnosis in medical
expression with explanation) or possibly a problem with your…(if you have only one
diagnosis in your mind say another relevant one in your DD even it’s not clear enough).

(If the pt has a serious problem pointing ahead, you can say , According to the
information you have given me and the physical exam, I am really concerned about
your symptoms as it might be a serious illness like caner or it could be a problem with)

(If the pt comes for follow up and found out a complaint ,According to the
information you have given me and the physical exam, I think your problem could be
due to..or… )

(If you didn’t have other than one diagnosis: According to the information you
have given me and the physical exam, I think you could have ….which is….

3- So, I need to run some blood tests and take some pictures (for echo or doppler use the
word: sound wave pictures) of your….. to find out exactly what the problem is and rule
out any serious illness
4- Once I receive the test results, we will meet again to discuss the final diagnosis and the
treatment options (Management plans), Does this sound good?
5- Okay Mr. / Ms.….., Do you have any other questions or concerns For me?
*If s/he asks you..answer it and ask did I answer ur question/address your
6- It was a pleasure meeting you ,--Shake Hands
7- Have a great day. Goodbye.
Notes On Examination
1-Any bleeding& Dizziness: order orthostatic studies/full neuro or cardio exam(Acc to cause)
2-DM: Fundoscopy, test sensation and vibration, pulses, auscultate carotids, examine feet
3-(Any Chest pain): check sinus, do a complete chest and cardio exam
4-(Any Pure Cardiac case):Complete cardiac exam in two positions/Auscultate carotids, leg edema,
Pulses.Ususally do Head & neck as it will be a case of dizziness or light headedness
5-Palpitations: check thyroid, extremities tremor, DTRs
6- (Any Joint pain): Auscultate Chest & Heart + Complete Joint Examination
7-Remember to use funduscopy in : HTN, DM, headache, confusion and visual complaints
8-Insomnia: check thyroid, DTRs
9-Any Pure psychiatric case: MMSE + (Neuro or Chest& Heart exam)
10-Confusion, forgetfulness: auscultate carotids, MMSE, funduscopy
11-Headache: Head& Neck / Chest& Heart / Neuro


“Remember every action of the SP is “PURPOSEFUL”.

1- Mr. Smith: I see you’re coughing, do you want a cup of water/a tissue?
2- Mr. Smith: I see a lesion in your face, what is that? Can you tell me what happened?
3-Mr. Smith: I see you’re holding your chest, are you in pain? Then ask if there is anything
you can do to help him/her feel more comfortable.
4- Mr. Smith: Yawning - "You look tired Mr. Smith, did you sleep well ?.
5-Mrs Smith, I see that you put the drape on your lap , are you cold?
6- Shivering SP: Could mean fever or also could mean the room is too cold .right ? so first do
ask the SP if the room temperature too cold for him/her.
7-If the patient is sad, "this must have been a difficult time for you, can you tell me about it?"
8-If he is wearing glasses , so something wrong with his vision. Or if he’s wearing a hat ,
maybe he’s hiding something underneath the hat. Be Picky

Very Imp Notes

1- If during any test, pt complains of any pain say " I am sorry, I need to do this test to
know what actually is the cause of your problem. Next time i will be gentle." (never avoid
any test fearing that it may cause pain to the SP. Just explain him the importance of the test)

2-Remember if you don’t remember the SP name you can say: Sir/ Madam

3- Never write anything while the SP is speaking. It's so important to write afterwards as you
will never remember what the pt said to you due to the stress of the exam and the time limit
of the pt notes.

3-Be careful with the pts that have Hearing Problems: don’t ask questions while you’re
washing your hand because they’re not going to be able to hear what you’re talking about.
Also never speak at the back of the pt unless you keep an eye contact

4-When after 10 min during the encounter ; when they do the announcement it may
interrupt you. Don't show any frustration then. Just wait till the announcement is over and
then carry on. Keep your smile and cool here. Don't ever show that you are tensed or
frustrated at any point in the exam.

5-Also while doing the physical never ever touch the gown of the patient. Your duty is to
just tie or untie the gown. Lowering the gown is done by the SP. Ask Now I am going to
examine your chest. For this I want you to lower your gown. Let me help you to untie your

6-If the CC is not related to CVS or RESPIRATION then only auscultate the heart and lungs.
No need to do more than that
If the CC is related to heart or lung ,Here you do a detailed Chest examination.

Physical examination will take a maximum of 3 min 40 sec including the washing of your
hands. Practice in such a way that you will not need more than 4 min for physical
examination in any case.

{time limit of examining Heart and Lung . You will just need 15 sec for heart
auscultation (3sec X 4 areas of the heart and 3sec for neck auscultation) and 20 sec for Lung
auscultation (2 places in front & 2 places at the back for 5 sec each ( auscultate for one full
respiration and then move to the other place.}

7-If the pt is sensitive to light , offer to pull down the shades or dim the lights.

9-Remember to get points for the checklist; I mean that don’t exhaust yourself in trying
getting the actual diagnosis and omitting asking about other items in (e.g social history ,
Cig,EtoH,Illicit, work,Travel At least),so get every point as much as possiple.

10-Remember the rule “right-right-right” (ophthalmoscope in examiner’s right hand—

patient’s right eye—examiner’s right eye) and the rule “left-left-left” (ophthalmoscope in
examiner’s left hand—patient’s left eye—examiner’s left eye)
11-(Don’t forget to use a new speculum for every patient for examining Ear)

12-It’s perfectly appropriate to ask questions about the history during the physical
exam.(Allow 4 to 6 mins for it)

13-You dont need to say what exactly you are looking for, unless they ask you - rather begin
with , like if you were looking up the eyes for pallor and icterus you could go:
Could you look up for me - arrite..and now could you look down please.....that looks fine"

14-Never ever after washing your hand or putting your gloves on to touch anything other
than the pt , (Not your face or the white coat – not the pen or clipboard to write something
that you asked during PE – Not your white coat ) Only The pt & the stethoscope. Make sure
that while you turn the knob of the sink off; don't do it with your hand but use a tissue to
turn the knob off after washing your hands.

15-Now before touching the Sp, place your hand on him and ask if s/he feels your hand cold
(if yes rub your hands and ask again )

16-Word choice is important.2 words which repeatedly get doctors into trouble are (feel and
Good) after performing a physical exam maneuver ,the patient might take it to mean that the
exam was normal. During the history ,if you say “good” after a patient answers your
question, it may come across as judgmental that you agree with her behavior. Use Thank
You or Thanks Or Simply Nod.

17-The word “feel” is appropriate to use in the history.{How does that make you feel} is
perfectly acceptable.
18- You may encounter a case in which the examinee instructions include the results of a lab
test. In this type of patient encounter the patient is returning for a follow-up appointment
after undergoing testing.

19- it is critical that you apply no more than the amount of pressure that is appropriate
during maneuvers such as abdominal examination, examination of the gall bladder and liver,
eliciting CVA tenderness, examination of the ears with an otoscope , and examination of the
throat with a tongue depressor.

20- Immediately after each patient encounter, you will have 10 minutes to complete a
patient note. Note: If you leave the patient encounter early, you may use the additional time
for the note.

21- If you have a case for which you think no diagnostic workup is necessary, write "No
studies indicated" rather than leaving that section blank.

22- You will not receive credit for listing examination procedures you WOULD have done or
questions you WOULD have asked had the encounter been longer. Write only the
information you elicited from the patient through either physical examination or history

23- When you are listening to breath sounds , Never ever lift the stethoscope while the pt
is taking his breath. And give time when you are listening to the heart (like count 1,2,3 then
move it to the next cardiac area till you are done with the 4 areas of the heart)

24- If you don’t know the answer of the challenging question, try to escape the answer by
logic way (as you are not required to give him/her accurate answer)

25- Practice PE so well that u can do them at any given time even if u have only 2 min left u
should be able to do something at least wash and check eyes so that you’ll get credit for it

26-There is no diagnosis called depression, It’s called and written(Major depressive disorder)

27-Important correlations:

 Paediatric cases: Sepsis or hidden infection is 1st in your mind

 Gynaecological cases: Thyroid disease is a must
 Anything related to the head: Head trauma must be in your mind
 Any bleeding: Think about bleeding disorders and Drug induced(v.v.v.imp)
 Any female or old pt: Abuse must be in your mind

28-Be careful of the time as almost always one system will be enough(the main one),as if
you did more than one and you are behind the 1 st alarm(5 mins remaining),you will not close
the case nor counsel the pt, so better to focus on the main system and do the other things.

29- Don’t writ WNL OR NORMAL in pt nots as they are not preferred but write down your findings
which are normal but write them down.
General Rules for PN:
a. Practice , practice , practice writing patiently within 9 minutes
b. Broken English is fine , like Google keywords ! Grammar can take a back seat
c. D/Ds don't have to be 5 in number ! You could write even 2 or 3 but its EXTREMELY IMPORTANT
that you arrange them in the order of relevance / possibility to the SP that you saw !
d. Treatment, consultations, or referrals NEVER to be in your work-up plan.
e. If you choose to write your patient note by hand, DO NOT touch the keyboard at that
station, because doing so will generate a blank patient note. If you accidentally touch the
keyboard, notify a proctor immediately.

Best Protocol to write PN:

1st- DD (1st one is the most likely one),(2nd one is another thing related to the same
system)(3rd one is something related to the age of the pt)(4th one is something related to the
sex of the pt.),(Last one is the least likely one )

2nd- Investigations (make a mental note of ordering the following according to relevance)
a- CBC w/diff-lytes (IN ALL CASES, First Investigation)
b- Pelvic/Rectal Exam.(2nd in OB/GYN) c-X-ray/CT/MRI(picture investigation)
d-Hormonal investigation (TSH, free t4,Testosterone,Prolactin,…etc)

3rd- Physical findings.(Write only what you did) 2-3 lines max.to save time then come

4th- History (it’s very tricky to manage the space for History, so practice it well to avoid
writing in a clumsy way), as it takes mostly half of the time so you wanna earn points.

Please stick to this order, even if you start getting confident with your timing, because there
will always be a case where you run out of time, so always get as much points as possible

"The patient note is considered a communication tool; poor legibility or spelling errors that interfere
with the patient note reader's ability to comprehend the note may have a -ve impact on your score.

In Paediatrics: you also have to write at the start about the informer.
The source of information is the patient’s mother. at the start of HPI.

Q. Can we write technical terms on patient notes while describing history.?

A. Except for the chief complaint - which must be in the patient's words, the rest MUST be
medical as you won’t have time and this is completely permissible as PN will be assessed by
doctors(e.g my period become lighter& longer = hypomenorrhea/oligomenorrhea)

Q. I am confused about the order of diagnostic workup. USMLEWORLD recommends

listing most specific first, in order of priority, but FA recommends listing most
simple and straightforward first. Could you clarify this for me?
A. I don't think that really matters - all relevant ones must come in the picture.
Order may be more important when you list down the Differential Diagnosis and I would
calibrate my order of Investigation list as per my D/D list.

Q: How about the telephone encounter:

A: leave the physical examination section blank ...or perhaps a better idea would be to write "Will be
done when Damian arrives at the hospital"
yo year-old KUB kidney, ureter, and
Advil Ibuprofen M male bladder
F female LMP last menstrual
Aldactone spironolactone b black period
Allegra Fenoxifenadine(allergy w white LP lumbar puncture
relief) L left MI myocardial
Augmentin Amoxcillin + Clavulanic R right infarction
hx history MRI magnetic resonance
h/o history of imaging
Bumex bumetanide c/o complaining of MVA motor vehicle
Celex citalopram NL normal limits accident
Coumadin warfarin WNL within normal limits NIDDM non-insulin-
Ø without or no dependent diabetes mellitus
Lexapro escitalopram
+ positive HCTZ hydrochlorothiazide
Lipitor atorvastatin - negative NSR normal sinus rhythm
Lopressor Metaprolol PPD Packet per day PERLA pupils equal, react
Maalox Antacid (Aluminum NSVD normal spontaneous to light and accommodation
Hydroxide and vaginal delivery po orally
UTD Up-To-Date PT prothrombin time
Magnesium Hydroxide)
NKA no known allergies PTT partial prothrombin
NKDA no known drug allergy time
Mylanta Antacid (Mg. OH and Ca. SH social history TIA transient ischemic
Carbonate) FH Family history attack
Nardil Phenelzine(MAOI) ETOH alcohol U/A urinalysis
cig cigarettes URI upper respiratory
Nexium Esmoprazole q every(as in Periods) tract infection
Paxil paroxetine LE lower extremity
A&O Alert and oriented
peptobismol antidiarrheal Abd abdomen
Plavix clopidogrel AP antero-posterior HEENT head, eyes, ears,
Prilosec Omiprazole nose, and throat
BS Bowel Sounds
Prozac fluoxetine SEM systolic ejection murmur
f/u = follow-up
HTN hypertension
Synthroid levothyroxine LAD lymphadenopathy IM intramuscularly
Tylenol Acetaminophen / FBS fasting blood sugar IV intravenously
Paracetamol NC/AT { Normocephalic, Atraumatic} JVD jugular venous
Zantac Ranitidine PA posteroanterior distention
Zocor simvastatin BUN blood urea nitrogen N/V/D
minutes mins nausea/vomiting/diarrhea
Zoloft sertaline CBC complete blood count GI gastrointestinal
Zyban Bupripion CCU cardiac care unit GU genitourinary
(Antidepressant + CHF congestive heart ED emergency department
smoking cessation ) failure SOB shortness of breath
ACEI: CP chest pain EOMI extraocular muscles
CVA cerebro-vascular intact
accident or costovetebral Ext extremity
Monopril=fosinopril angle UE upper extremity
Accupril=Quinapril CVP central venous
m, r, g (murmurs, rubs, gallops)
CCB: CXR chest x-ray NT,ND Non tender, Non
Norvasc=amlodipine DM diabetes mellitus distended
DTR deep tendon reflexes B/L Bilateral
Calan or isoptin = verapamil
PMI (Point of maximal intensity) CTAB clear to auscultation bilaterally
RBS random blood sugar IBS Inflammatory bowel
RRR (regular rate& rhythm) syndrome
Ask about what for if you don’t know the months mos G1P1(gravid once/have one baby)
drug(Not wrong)
Cranberry: UTI Ginko: For improved blood flow – people worried about stroke, CAD
Echinacea: URTI Ginseng: For increased memory , anti stress – people worried, or afraid
Garlic: High cholesterol of getting Alzheimer’s
Ginger: Motion sickness for N&V St. John’s Wort: Depression
Saw Palmetto: BPH
Physical exam
GA: Pt is conscious and oriented and ( in no acute distress/leaning forward/fatigued&
anxious/holding tissue with blood in it…)
VS: copy vital signs or the main thing related to the case

HEENT: { No bruises – No LAD nor JVD}

Head : NC/AT
Eyes : EOMI , PERRLA, Fundoscopy no papilledema no retionopathy , No visual field defects , Conjunctiva: No icterus,
nor pallor
Ears : Canals w/o abnormalities, TM clear , Auricle or peri-auricle :No tenderness , no stigmata of infection,
Weber test no lateralization; Rinne test (revealed AC>BC)
Nose : Nasal turbinates not congested
Neck : supple , no thyroid enlargement , no LAD , no limitation of ROM, (-) JVD, no carotid bruits.
Throat : no tonsillar enlargement , erythema , exudates , vesicles.

Palpation:(-) tenderness to palpation
Percussion: Clear to percussion Bilat.
Auscultation: Clear lung fields. (-) rales, rhonchi, wheezes

Inspection/Palpation: PMI not displaced
Auscultation: S1, S2 / RRR / (-) m, r, g

Inspection: (-) scars (e.g CS scars) or skin abnormalities
Auscultation: (+)BS in 4 Q / OR hypoactive BS
Palpation: Soft , NT , ND , CVA tenderness (+/-)
Percussion: Tympanic to percussion in 4 Q / (-) organomegaly or masses
Special maneuvers : (-) rebound , Murphy’s , psoas

A&O x3 , Concentration, Memory good
CN: II-XII : intact
Motor strength: 5/5 throughout except for /LE or RE ( 3/5 if he can move the limb)
Sensation: intact to sharp &dull
DTR : 2+ intact& symmetric /or Brisk reflexes.
Cerebellar : finger to nose: intact, Gait : Bradykinetic, takes small steps, Romberg: –ve
Special tests : Plantar reflex: Normal / Kernig or Brudzinski (-)/ Straight leg raising –ve bilaterally

Inspection: No obvious deformities or signs of trauma
Palpation: No spinous process or paraspinous tenderness
ROM: No limitations in movements
Motor: 5/5 LE B/L(Lower extremity / Bilateral)
Sensation : intact to sharp & dull.
DTR: 2+ patellar , Achilles
Pulses :2+ symmetric , DP, PT(dorsalis pedis – posterior tibial)

UL: No clubbing, cyanosis, or edema. No tremors, rash or excoriations.
LL: No pedal edema,
All other items of the lumbosacral system.
Medical Term Layman English
Abatement A decrease in the severity of a pain or a symptom
abcess cavity with pus
abdomen Stomach, Belly, Tummy
ABDOMINAL Pertaining to body cavity below diaphragm which contains stomach,
intestine, liver, and other organs
abduction push out / to take away from, like to "abduct" someone
Abortion (1)Induced abortion: is a procedure done to end pregnancy.
(2)Spontaneous abortion= miscarriage: is a naturally occurring abortion.
3)Therapeutic abortion: is an induced abortion required to save the life
or health of the mother.
Abscess A swollen, inflamed area where pus gathers.
Abuse Do your parents(boyfriend/girlfriend, roommate, husband /wife)treat you
Adjuvant Therapy therapy provided to enhance the effect of a primary therapy
alcohol liquor
alopecia hair loss
Alzheimer's Disease A brain disorder characterized by memory loss and behavioral changes
due to abnormal, age-related breakdown of nervous tissue in the brain/ age
related memory loss
amenorrhea absence of menstrual periods=missed periods
Anal fissure tear in the anal canal
anemia having less than normal number of blood cells
Angina Chest Pain due to Reduced Blood Supply to the Heart
Angiodysplasia swollen and weak vessels
Anticoagulant (heparin, etc) blood thinner
anus back passage
appendectomy surgical removal of your appendix
Appendicitis Inflammation of the appendix
appendicitis an inflammation of a tiny structure of your intestine that we call appendix
appendix Your appendix is a finger-shaped pouch that projects out from your colon
on the lower right side of your belly
Appetite Desire for food intake
Arrythmia It is a disturbance in the rhythm of heart beats
Asthma repeated episodes of difficulty breathing due to some allergens and
irritable airways
Atrophic oral decrease in size of a mouth
Axilla Armpit
Bipolar disorder Ups and downs in your mood
Bronchoscopy A thin tube connected to a camera to look into your respiratory airways
carpometacarpal joint knuckle
cervix neck of the womb
Cholecystitis inflammation of the Gall Bladder which is a sac under your liver
cholelithiasis gall stone in biliary tract
chrons disaese chronic inflammation of digestive tract
claudication limping
Clavicle Collar bone
colitis infection of colon
Colonoscopy Visualize your bowel using a scope passed through your bottom and we
can take a sample from any masses there
Conjuctivitis Inflammation/infection of outer layer of your eye
Connective tissue is tissues between bones and muscles
constipation Passing hard stools or unable to pass any stools
convulsions sudden, jerky movement of limbs that are out of control of the patient
CT - head serial x-ray of the head and brain
CT scan It is a high definition imaging test for the internal organs / A Modified X-
ray Imaging technique to visualize the internal organs in serial pictures
Cushing's Disease Disease characterized by raised levels of steroids in the body
Cyanosis blue nails on your fingers and toes
Deep palpation I need to press a little more deeply on your belly.
deep tendon reflexes(DTR) muscle response
Dementia Forgetfulness
Diabetes mellitus A disease that causes high sugar levels in your blood
diaphoresis excessive sweating
diarrhea Loose bowel Motions
Diplopia Double Vision
Disc herniation the disc supporting the backbone is out of place or bulging out
Disease Medical condition
Diuretic Pills for Hypertension? Were you taking a 'water pill' for your Blood Pressure ?
DIVERTICULOSIS out pouching of intestine wall
Dizziness Light Headedness, A feeling of an impending faint
Dizziness Reeling sensation
Drape Sheet/cover.
dyschezia pain while passing stools
Dysfunctional Uterine Bleeding Heavy or irregular menstrual bleeding that is not caused by any evident
underlying physical abnormality
Dysphagia blockage of the food pipe resulting in difficulty in eating or drinking/
Difficulty while swallowing
dyspnoea difficulty in breathing
dysuria burning urination
EKG/ECG/cardiogram electrical recording of heart beat
ECHO special test to visualize your heart by sound waves
ectopic pregnancy pregnancy occurring outside the womb lining
edema retaining liquid, swelling of your feets or eyelids.
EEG recording electrical activity of brain
heart murmur a sound between the two normal sounds of the heart that sounds like
someone blowing, and can be caused by different heart pathologies or may
be a normal finding in some cases
MRI a machine that uses a big magnet to obtain detailed pictures of your brain
or body
stroke decrease blood supply to brain due to blockade or constriction of blood
tachycardia racing heart
tubal sterilisation having tubes tied
ultra sound An ultrasound scan uses high-frequency sound waves and computer
technology to provide images of your internal organs.
umbilicus belly button
Gynaecological health Women’s health
seizure fits

If you find yourself obliged to use a medical term that the patient may not understand, try to offer a quick
explanation. Don’t wait for the patient to ask you for the meaning of a term, or you may lose credit IF S/HE asked
you what does this mean.
General Scheme for Writing the History
You must write it down before knocking on the door to arrange your items and make it easy
for you to write the PN , and not to forget anything when you are out

O nset L ocation 1- Most common one.
C ourse(sudden/over time) I intensity 2- Related to the same system
C ontext(circumstances) Q uality 3- Related to pt’s age.
C onstant or intermittent R adiation 4- Related to pt’s sex.
P rogression(worse or better) A lleviating 5- Least likely one.
D uration A ggravating
F requency A ssociated(ROS)
ROS(Part of the associated symptoms) PMH
P (Episodes/HTN,DM,CHOL)
1- System related Qs(e.g rest of GIT A (Meds/Food/Else)
Questions) M (Meds/OTC/OCP)
2- DD – related Qs. H (+/-)
S (+/-)
F (Alive,well/ + or - )
O (If relevant)
S (Active or not/e whom)
S (Cig/EtOH/Illicit)(Job/Travel/ stress/
living conditions)

General Scheme for Writing the Patient Note

General History: Pediatric History:


ROS: -ve except for the above ROS:

OB/GYN: (Only In Female & Relevant Cases) Allergies:

Allergies: Medications:

Medications: PMH:

PMH:(Disease & ttt) Birth history: uncomplicated NSVD

PSH: Dietary history:

SH: Cig-EtOH-Illicit drugs-sexually active or not Immunization history: UTD

FH: (+ only ) or write non contributory Developmental history: Last checkup- WNL

Physical Exam:

System Specific: (Abdomen/Neuro/Lumbosacral): Each one in detail
Mini Cases
Headache:(As any pain analysis) Confusion/loss of concentration& memory
1-Migraine (Aura=sensory-auditory) loss:
2-Tension & cluster headache (Specific time 1-Repeated Hypoglycaemia } (dizzy-light headed)
every day/runny nose during attack) 2-Arrhythmia (passed out/racing heart/chest pain)
3-Eye disorder(Refractive errors)- Temporal 3- Alzheimer’s disease(Most Common-dementia Q)
arteritis(proximal Joints/loss of vision) 4- Vascular dementia(Neuro Q)
4-Sinusitis (URI=Runny nose-cough) 5- major depression with pseudodementia(feeling sad).
5-Teeth(dental caries-abscess) 6- Hypothyroidism (Temp.-skin-hair-voice)
6-Head trauma(Falls= Very imp) 7-Chronic subdural hematoma}Falls (Very imp)
7-Meningitis (Fever-Neck stiffness) 8- Normal pressure hydrocephalus(mem-urine loss-gait)
8-Increased ICP (SAH-tumor)- N,V, Weakness 9- Intracranial neoplasm(headaches-N/V-weakness)
waking from sleep/Speech difficulty. 11- Alcohol withdrawal syndrome (sudden quitting )
9-Pseudo tumor cerebri: OCP 12-Neurosyphilis(STDs).
Depression: Psychosis/Visual-Olfactory hallucinations
1- Adjustment disorder with depressed mood/ 1-Schizophrenia(Fx- Auditory hallucinations)
2-Normal bereavement(Any stressful event) 2-Brief psychotic or Schizophreniform disorder (1st is for
3- Major depressive disorder(Fx) <1month ,2nd is between 1 month & < 6 months)
4- Abuse***(woman-elderly=Very imp.) 3- Psychotic disorder due to a general medical condition
5- Dysthymic/ Cyclothymic disorder(mood (Brain tumor/encephalitis: Headache-N/V-fever-neck
swings- Ups & Downs over years) stiffness +Neuro Qs-Visual or hearing problems)
6- Hypothyroidism. 5- Substance-induced psychosis
7- Substance-induced mood disorder 6-Narcolepsy(daytime sleeping-naps-trouble
8-Schizoaffective disorder. (Hallucination + sleeping Qs)
Depression) 7-Seizure(Describe-witness/Before-during-after/Fx)
Dizziness vs light-headedness(Find Loss of consciousness(LOC)=Blackout
out What does s/he mean by dizziness) 1-Seizure(Before:sweaty-sounds-flashes-racing
As it’ll be cardiac/neuro case or Ear case heart/During:shaking-bite tongue-loss bladder/
{ (Falls± hearing loss/tinnitus) ±URI} After: confusion-concentration)/vision
1-Ménière’s disease(HL+ vertigo>20mins) 2-Syncope(vasovagal-dehydration)stress/diarrhea
2- Labyrinthitis (HL)& Vestibular neuritis: 3-TIA or Stroke (Hge-Weakness–speech- gait)
No HL (Both after URI) 4-Cardiac arrhythmia(dizzy-palpitation-tachycardia)
3- Acoustic neuroma(HL+V,VII,IX&X ) 5-Severe aortic stenosis/MI(Chest pain)
4- Benign positional vertigo=canalolithiasis: Secs 6-Pulmonary embolism (SOB/LOC/Fever)
5-Orthostatic hypotension due to dehydration(e.g 7- Hypoglycemia(N/V-dizzy–lightheaded-Belly pain)
diarrhea/drug)(sudden sitting or standing up) 8-Substance abuse/overdose(LOC 1st then fall)
6-Vertebrobasilar insufficiency (vision/ICT) 9-Head trauma (Any history of recent trauma)
Hearing Loss:(To all sounds or not) Blurry vision:
1-Presbycusis(SNHL-old age-AC>BC) 1-Catarct.(Old age)
2. Cochlear nerve damage due to loud noise(Can 2-Macular degeneration(How is your night vision)
you locate the source of sound) 3-Closed angle Glaucoma.(wear glasses or Contacts)
3. Otosclerosis(CHL-old age -AC<BC) 4-DM(Excessive thirst late/need to drink more)
4.Otitis externa/media(Unilat. CHL) 5-Hypertensive retinopathy(history of LOC/seizures)
4. Ménière’s disease(d.t endolymphatic 6-Temporal arteritis(Complete loss of vision at any
disruption in inner ear from syphilis) time/headache/weakness/joint/jaw pain)
5. Acoustic neuroma(Neuro Q/Speech 7-Brain lesions(Headache-N/V-weakness).
understood or not) 8-If unilateral (Trauma /FB/or infection to the eye)(discharge
6. Ototoxicity(aminoglycosides/aspirin) -Halos around light-eye pain/red/swollen)
Weakness/Numbness(CNS- Tremors: what context did your hand shake the
Endocrine – Psychological causes) most?
1-Transient ischemic attack (TIA) 1-Physiological tremor: (made worse by, stress
2-Stroke ,hyperthyroidism (Temp-racing heart-Diarrhea-wt)
3-Seizure -Todd’s paralysis. 2-Postural tremor: (absent at rest, present on
4-Multiple sclerosis(eye/different lesions maintained posture- affects hands/head,) Causes:
5-Hypoglycemia *Benign essential tremors: Fx., improves with alcohol.
6-Diabetic/Alcoholic Peripheral *Thyrotoxicosis.(vision changes-nervous-palpitations)
neuropathy *Alcohol withdrawal syndrome. (seizures-hallucinations)
7-Megaloblastic anemia(Vit B12 def) *Drug-induced(B-agonist ,valproate, lithium)
8-Guillain-Barré syndrome 3-Tremor at rest: Idiopathic Parkinson's disease (PD)
9-Polymyositis (Dementia Qs /Depression ”esp. memory&
10-Myasthenia gravis concentration” -urinary changes/ Gait instability +
11-Horner’s syndrome changes in voice or handwriting / constipation)
12-Conversion syndrome 4-Intention tremor: cerebellar dis. (MS,TIA,Stroke)
Neuro&CVS Qs(occur only with movement &subside with rest)
5-Epilepsy(Hx of seizures)
Insomnia(Difficulty sleeping): Fatigue=loss of energy=Not himself:
1-Stress-induced insomnia as in Generalized 1- Depression-PTSD-Adjustment disorder(In full)
anxiety disorder or Hyperthyroidism (Sweating- 2-Hypothyroid(Temp-skin-hair)/(menstrual changes)
Irritable-bowel changes-weight change) 3- Sleep disorder(Obstructive sleep apnea: snoring-
2-Caffeine-induced insomnia(shaking hands- difficulty” falling-staying” asleep–early awakening-
racing heart) daytime sleeping)
3-Obstructive sleep apnea(snoring-daytime 4- Domestic abuse. (safe at home)-Very imp
sleeping- naps) 5- DM-DI (1st diagnosed or uncontrolled-Urinary
4-Insomnia with circadian rhythm sleep disorder symptoms)
(jet lag or shift work) 6-Chronic Infection anywhere(Fever-chills)-e.g HIV/TB
5-Insomnia related to major depressive disorder 7-Any Cancer-paraneoplastic Syndrome(GIT symptoms /
(Sadness-Early spontaneous awakening) stool color ”black/red/clay” - Chest symptoms)
6-Adjustment insomnia(stressful event) 8-Anaemia (feel weak-racing heart-vomit blood)
6-Diseases that interrupt sleep(Cardiac or Resp., 9-Chronic fatigue syndrome(sore throat-myalgia-
Arthritis: pain/Restless leg syndrome arthralgia-headaches-generalized weakness)
Frequent Falls: Jaundice
1-Cerebellar disease (gait/speech). 1-Extrahepatic biliary obstruction:{Pancreatic cancer-
2-Parkinson’s disease(memory problems) Cholangiocarcinoma} (General Qs/Itching)-
3-Diabetic neuropathy(urinary/sexual Choledocholithiasis -Cholangitis(GIT Qs)
problems) 2-Viral hepatitis (Eating-Travel-Blood-Sex-Drugs)
4-Brain tumors(shaking movements). 3-Alcoholic hepatitis(Stool, urine color, belly pain)
5-Inner ear disease(Meniere-labyrinthitis) 4-Primary biliary cirrhosis(Fx-Itching)
6-Fractured hip(any broken bones before 5-Acetaminophen liver toxicity(Especially if alcoholic)
from falls/living conditions) 6-Hereditary Hemolytic diseases e.g sickle cell (Blood Qs)
Sore throat: Night sweats:
1-Viral(EBV/Common cold/Adenovirus/HIV} or 1-Chronic infections:
bacterial(strept./Gonococcal) pharyngitis A-Tuberculosis(General Q + Chest Q).
(General Qs+URI Qs+Ulcers+fever+LN) B-Acute HIV infection.
2-Tonsillitis(Muffled voice/pain go to ear) C-Subacute bacterial endocarditis(SBE)-Cardio Qs
3-Infectious mononucleosis (EBV) (Ill contacts 2-Cancer( Lymphoma – Leukemia)=Any swellings/
+glandular fever, rash +generalized Feeling weak )
fatigue+ Abd pain ”spleen”+ Hepatitis 3-Hyperthyroidism
”Jaundice/stool &Urine+GIT Q” 4-Menopause(Pain with sex-hot flashes)
4-Acute HIV infection (risky pts: sex/drugs) 5-Drug-induced ( GnRH agonists, antidepressants)
Cough/shortness of breath Chest Pain:
1-URI-associated cough ”mainly viral”(General Cardiac causes:
Qs/runny nose-sore throat/fever) 1-Angina/MI-(Cardio Qs-Cocaine use)
2-Bronchitis (Acute-Chronic) (Chest Qs) 2-Pericarditis(past URI, pain when you breath in)
3- Asthma (Fx-Pet or animal exposure). 3-Valvular HD(MVP)
4- Pnumonia( Urine Legionella antigen, Lung Causes:
serum Mycoplasma PCR, PCP”AIDS”) 4-Pleurisy(Unilat.-abrupt&sharp-lower lat. Chest)
5- TB(Exposure to TB specific/last PPD) 5- Pneumonia-TB(fever&chills-tachypne-cough)
6- Lung “cancer-Abscess”(weight/Appetite) 6-Pneumothorax- PE(LOC-racing heart-dry cough)
7-ILD(dry -wt loss-progressive dyspnea) Other Causes:
8-Wegner’s granulomatosis(URI/LRI/Renal) 7- Muscle(strain-costocondritis) (painful to touch)
9-GERD(heartburn/cough at night+GIT Q) 8- Esophagitis/Esphageal spasm.(GIT Qs)
10-Heart failure(Fatigue-edema-gradual) 9- GERD/Peptic ulcer dis.(postprandial pain)
Palpitations: Weight loss
1-Hypoglycemia(related to meals/sweating I-With increased appetite
confusion/fine tremors) 1-Hyperthyroidism(anxious, sweating ,racing heart,
2-Cardiac arrhythmia(dizzy-LOC-confused- shaking hands, skin, voice, hair, period changes)
fatigue) 2-Uncontrolled DM
3-Heart disease{Angina(chest pain- 3-Pheochromocytoma
difficulty breathing)or valve dis. MS/MVP} II-With decreased appetite
4-Hyperthyroidism(hot intolerance) 4-Malabsorption(changing diet/GIT Qs)
5-Anaemia(Tired-pallor-weakness) 5- Chronic infections{HIV infection(Sex-Blood)-TB-SBE}
6- Pheochromocytoma(sweating-anxiety) 6- Cancer(Rash-bruises-blood in coughing , urine or
7- Carcinoid(belly pain-diarrhea-wheeze) stool-any swollen glands-H,N.V)
8-Excess Caffeine intake 7- Anorexia nervosa/Depression(Feel sad/body image)
9-Panic/anxiety attacks(facial flushing-SOB) 8-Drug induced:diet drugs/laxatives/amphetamines
Weight gain(Obesity) Dysphagia(To water-food –which 1st or both)
1-Pregnancy(N/V,Breast-urinary changes) 1-Esophagitis (Candidiasis, CMV, HSV, pill-induced-
2-Hypothyroidism(cold intolerance-dry corrosive liquids accidently or intentionally-GERD)
skin-falling hair-constipation-voice- Painful or not
menstrual irregularities) 2-Systemic sclerosis(skin changes/GIT Q)
3-Familial obesity 3-Esophageal cancer (Smoking/Alcohol)
4-Cushing’s syndrome(mood changes, prox. 4-Achalasia(any chocking sensation)
weakness, bone pain, high BP,BS) 5-Plummer-Vinson syndrome(Feeling tired,/racing
5- Polycystic ovary syndrome(Infertile/extra heart)
hair growth anywhere) 6-Esophageal spasm(Chest pain)
6- Drug-related obesity(Steroid-OCP-lithium 7-GERD(heartburn/cough)
7- Smoking cessation 8-Neuromuscular disorders(CVA/myasthenia gravis) (any
8- Causes of generalized edema (CHF-RF- weakness/Fatigue/painless dysphagia /problems
CLF)chest & heart general Qs with chewing or choking).
9- Atypical depression(sad-tired-sleep)
10-Eating disorder(binge eating):food type
Nausea/Vomiting Upper GI bleeding:(Hematemesis)
1-Pregnancy(test-relation to meals) 1-Bleeding peptic ulcer(Gastric-duodenal)
2-Any GIT infection(Gastritis/GE/appendicitis/ 2-Gastritis/Oesophagitis.
IBS/(abd. Pain-food poisoning) 3-Mallory-Weiss tear
3- Renal disorders (UTI)(fever-loin pain) 4-Esophageal varices
4- Increased ICT (due to mass effect/Infection): 5- Cancer(Oesophageal/gastric)
(headache, stiff neck,vertigo,weakness) 6- Medications: NSAIDs, anticoagulants, steroids,
5-Acute labyrinthitis/Meniere disease (Ear Qs) thrombolytics. VERY imp
6-Acute angle closure glaucoma (Eye Qs)
7- DM=DKA(Urinary Q)
Constipation: Abdominal pain(Fever or not/generalized or
1-Diverticulosis(Diet vegetables, fruits) localized)
2- Colorectal cancer(GIT Q/sense of Upper:
incomplete evacuation) 1- GERD
3-Bowel obstruction(Abd cramps/pain) 2-Gastritis /Gastric Cancer(Heart burn/melena/belching
4-Anorectal disease(fissure,rectal prolapse) 3-Peptic ulcer (disease / Perforation)-Relation to food
5-Hypothyroidism(Skin-Hair-Voice-Cycle) 4-Functional or non-ulcer dyspepsia(most common cause
6-DM(diabetic gastropathy)(Cardio/Urine) of chronic dyspepsia).
7-Neurological disorders(Stroke/ Parkinson 3-Cholecystitis/choledocholithiasis/ Ascending or Sclerosing
/scleroderma) cholangitis-Types of food that exacerbate the pain
8-Medication- induced(iron-opiates)Imp 4- Acute viral hepatitis-itching/tired-travel/blood/sex
9-Functional(1ry) constipation.(no abd pain) 5-Acute/ Chronic pancreatitis-fever/tachy/jaundice /
Diarrhea alcohol
1-Infectious diarrhea (gastroenteritis)— 6- Rib fracture-trauma/falls
bacterial(Salmonella/shigella,C.jejuni Lower:
Yersinia) Viral(Hep A, Rota virus, HIV), 1-Volvulus or other intestinal obstruction/ perforation
parasitic (ascariasis , giardiasis), protozoal 2-Gastroenteritis(fever/N,V,D)
(Amebiasis) {fever-sick contact } 3-Mesenteric ischemia/infarction(Heart Qs)
2-Food poisoning (S.aureus- B.cereus) 4-Diverticulitis (Fever/abd. Distension/mass)
3-Traveler’s diarrhea(travel-E.coli) 5-Inflammatory bowel disease(CD/UC) (wt loss/diarrhea)
4-Pseudomembranous colitis (Antibiotics) 6-Appendicitis(rigidity/localized pain/+ve signs)
5-Hyperthyroidism(Anxiety-hot intolerance Back:
-tremors-racing heart-Cycle) 1- Nephrolithiasis(severe&sudden/agitated/Urinary
6-Tumor(VIPoma) frequency with dysuria &hematuria)
7-Bloody diarrhea(Ischemic colitis/IBD/ 2-Pyelonephritis
Cancer/ Diverticulitis) 3-cystitis(Dysuria-Nocturia-frequency-fever)
Alternating Constipation & Diarrhea 4-Renal cell carcinoma
1-Irritable bowel syndrome(Not emptying GYN/OBST Causes
your bowel) 7-Ruptured/Torsion ovarian cyst(sudden,fever)
2-Inflammatory bowel disease(CD,UC) (General 8-Ectopic pregnancy(Amenorrhea/vaginal bleeding
Qs/Blood in stool/Tenesmus) /urinary frequency)
3-Malabsorption{Celiac disease(feel bloated 9-PID(metrorrhagia,fever,chills,urinary discomfort )
-Chronic pancreatitis(Chronic belly Pain)} 10-Endometriosis(pain “with menses=dysmenorrhea
5- GI parasitic infection /with intercourse/ increased with defecation)

Hematochezia(Blood per rectum): Erectile dysfunction(ED)(on a scale from 1 to 10

(blood before, during, or after being 1 is flaccid&6 is adequate for penetration)-
defecation) sexual desire
1-Diverticulosis(Diet, alternating 1-Organic ED {HTN-DM-hyperlipidemia-“Leriche’s syndrome-
Constipation& diarrhea, abdominal Pain (angina, leg claudication, diminished pulses, hair loss,or thin)-
relieved by defecation) *Endocrine: Pituitary Hyperprolactinemia-Hypogonadism
2-Anal fissure(pain with defecation) *Trauma: local / surgery(Prostate)
3-Hemorrhoids(mucus) *Drug-related:Cimetidine-HCTZ-Propranolol-Amitriptyline
3-Inflammatory bowel disease: UC/CD *(Alcohol-Smoking)-induced ED
4-Infectious diarrhea (Travel- fever/chills - *Peripheral neuropathy(Neuro Qs/orthostatic BP
Abd pain) 2-Psychogenic ED (depression-PTSD-Performance
5-Ischemic colitis(bloody diarrhea-severe anxiety) =stressful events/nocturnal or morning
cramping disease)-Heart Qs erection/ premature ejaculation/conflicts with
6-Colon cancer(Fx., fatigue wt loss) partner -is she satisfied?
7-Bleeding disorders(rash-easy brusing-
bleeding gums- Fx) 3-Peyronie’s disease(curved penis)=painful erection
Dark Urine: Hematuria:
Must ask about : 1-UTI”Pyelonephritis-Cystitis-Urethritis-Prostatitis”
*If the bleeding varies in severity (fever,chills,N/V, painful ejaculation,terminal
between voiding. hematuria,scrotal swelling)
*If it's worse at the beginning, middle, 2-Stones”kidney-ureteric-bladder-Urethra” (loin/scrotal
or end of urination. pain – Fx- possible bladder distension)
*Presence of clots or not 3-GN(Post infectious: URI/Gastroenteritis )recent
4-Pulmonary renal syndromes (Wegner granulomatosis/Good
1-Foods:Beets,Blackberries Pasture’s Syndrome – SLE) Chest Qs-painless hematuria
2-Drug-induced (rifampin/Penicillin/ 4-Polycystic kidney disease (Fx-HTN)
cyclophosphamide”cytoxan”) 5-Trauma(abd or flank /vigorous exercise)-Very imp
3-Hematuria causes 6-BPH(obstructive symptoms: Hesitancy-terminal
4-Rhabdomyolysis (exercise/accidents) dribbling-poor stream-strangury- sense of
5-Paroxysmal nocturnal hemoglobinuria incomplete bladder emptying)/(Irritative symptoms:
6- Chest symptoms for Pulmonary renal syndrome urgency, dysuria, frequency, nocturia)
hematuria/ clots
8- Bleeding disorders(e.g sickle cell anemia:
rash/easy bruising/severe abd pain)
Any Joint Pain(Limb Pain) 1-Shoulder(Arm) pain
*Constitutional Qs: fever-chills-wt loss 1-Shoulder Dislocation----------}Both have limitation
*Eye(Dry-red-decreased vision- 2- Fracture.(Humeral-clavicle)-}in all ROM
sensitivity to light): {Sjogren’s syndrome- 3-Rotator cuff injury/Frozen shoulder.(Increased pain on
SLE-Ankylosing spondylitis-Temporal arteritis} elevation of arm or on all movements)
*Rash- ulcers ”oral-genital” 4-Tendonitis(Max. pain at acromion/difficulty
*Resp Qs sleeping at affected side)
*Blood in urine 5-Adhesive capsulitis(Progressive restriction of
*Neuro Q(Weakness/drop){SLE-Behcet} - movements-no tenderness on palpation)
Focal numbness/weakness/headache 6-Sprain.(Falls/LOC)
{Polymyositis/dermatomyositis} 7-Elderly abuse.(Living conditions)-Very imp
*GIT Qs(Diarrhea or dysuria/STD 8- Arthritis. (Other joint affection/MSK Qs/
”gonorrhea”) {Reiter’s} -UC/CD{ankylosing constitutional symptoms)
spondylitis} 9-Refered pain
*Travel: History of recent tick bite A- Angina/MI/Dissecting aortic aneurysm (Cardio Qs)
*Occupation B- Acute pancteatitis- Cholecystitis- Cholelithiasis
*Ability to function (dressing/ grooming / (Abdomen Qs)
writing/ walking)
*Smoking worsens RA
Wrist Pain: Hand Pain(Fingers Pain):
1-Domestic violence 1-SLE(Non destructive/small joints)
2-Carpal tunnel syndrome(intermittent 2-Rheumatoid arthritis(MCP/PIP)
paarathesia-Pain worse at night & with 3-Psoriatic arthritis/ Parvovirus B19 infection(Small joint
repetitive movements-Job- Phalen affection)
&Tinnel:+ve) 4-6Carpal tunnel syndrome
3-Tenosynoviitis(pain worse on radial 5-Osteoarthritis(DIP)
aspect–Pain at snuff box-Finkelstein+ve 6-Disseminated gonorrhea(unprotected sex with
4-Arthritis Multiple partners)
6-Sprain or strain
3-Radiculopathy of nerve roots C6
and C7 in cervical spine (Any neck pain)
Hip Pain: Knee pain:
1-Hip dislocation—traumatic 1-Trauma (fall-sport-elderly abuse)-(Cruciate
2-Hip fracture (History of repeated falls- ligament/meniscal ) injury
Neuro Qs) 2-Arthritis:
3- Pelvic fracture(History of accidents) A- RA(other joints involve /Rheumatologic Qs)
4- Osteoarthritis(no constitutional B- Reiter’s $ (GIT-Dysuria)-
symptoms- Overweight) C- SLE(Oral ulcers/photosensitivity/rash/mood)
5-Avascular necrosis(SLE-oral ilcers-rash) D- Osteoarthritis(no constitutional-only local)
6-Bursitis E- Septic arthritis (Gonococcal/ Non-gonococcal)
7-septic arthritis (Constitutional Qs/sexual partners )
5-Pseudo gout.
6-Ruptured popliteal cyst
Heel Pain: Neck Pain(Cirvicalgia): Circumstances
1-Plantar fasciitis” most common 1-Prolonged postural (falling asleep on sofas&chairs)
cause”(time of max. pain) 2-Tension Headache-Stress/strain(Most common)
2-Calcaneal Stress fractures- (Previous 3-Trauma: acute (flexion, extension)-car accidents
fractures or trauma to heel or ankle) 4-Degenerative arthritis: cervical spondylosis
3-Achilles tendinitis 5- Neurological: cervical prolapse – Meningism
4-Arthritis(Reiter’s -RA-osteoarthritis-Gout) (Meningitis-SAH) – Infection Qs/All Neuro Qs
5-Ankle sprain(twisted-falls)-Very imp 6- Inflammatory: RA-polymyalgia rheumatica-
6-Foreign body-Spurs (warmth, erythema, ankylosing spondylitis (Full Rhematolgy Qs)
pain, indurations, or a fluctuant mass) 7-Metabolic:osteoporosis-osteomalacia
7-Osteomyelitis(Constitutional Qs) 8-Referred pain: shoulder/tempromandibular or
8-Foot deformities(flat foot/ Ingrowing acromioclavicular joint or MI (heart &chest Qs)
nail/Hammer toe/Bunion) 9-Malignancy:secondaries (Weight changes)
9-Tarsal tunnel syndrome.
Leg Pain: Lower Back Pain:
Context (moving furniture, bending/ twisting,
Bilateral: trauma)/Timing(disturb sleep)
1-Peripheral vascular disease (intermittent
claudication-rest pain) 1-Disk herniation(Urinary or fecal incontinence/leg
2-Lumbar spinal stenosis(pain in lower back
/controlling urine or stool) 2- Vertebral compression (tumor fracture)(Trauma/Abuse)
3-Osteoarthritis(knee-ankles) obesity 3-Lumbar muscle strain (lifting-relieved by analgesics)
4-Diabetic polyneuropathy(urinary changes)
4-Lumbar spinal stenosis(Aging-relieved on leaning
5-Thromboangiitis obliterans.(Hidden cancer)
forward or pushing carts)
5-Degenerative arthritis.(Osteoporosis-osteomalacia)
Unilateral: 5-Ankylosing spondylitis (Fx/stiffness in the morning)-
6-Superficial venous thrombosis (any skin Very imp
changes -dilated painful warm veins) 6-Renal (UTI-Stones) (Fever, night sweats)Very Imp.
7-DVT(trauma to leg-Fever-Chest Qs) 7-Malignancy:
8-Baker’s cyst rupture(Any leg swelling) *Cancer metastases(Prostate=difficult urination
9-Myositis{Polymyositis/Inclusion body /Breast=masses-discharge-skin change) -
myositis}Any trauma/injury to leg/statin *Multiple myeloma (other bony pain-hypercalcemia
10-Cellulitis(red-swollen-warm to touch) ”constipation, excessive thirst & urination” –
11-Radiculopathy from herniated disc repeated infections)
8-Women Causes:
*Endometriosis(cyclic pelvic pain)
*PID(Vaginal discharge-fever)
*Ovarian Cyst(Abd pain- urinary frequency)
The DD depends on the main complaint which is due to DM complications or due to drugs
of the pt. side effects
Hypertension Follow Up: Diabetes Follow-up:
1- Drug induced ED. 1. Insulin-induced hypoglycemia.
2- Hypogonadism 2. Peripheral neuropathy (Diabetic-Alcoholic).
3- Major depression. 3. Multiple myeloma.
4- ED caused by vascular disease(HTN/ 4. Diabetic autonomic neuropathy, vascular
DM/Hypercholesterolemia) disease, or medication-induced erectile dysfunction
--------------------------------------------- --------------------------------------------------------
Disease analysis Drugs=treatment analysis (Same for drug refill)
1-Onset(when you were diagnosed with) 1-Name:What are the medication you are on?
2-Checkups(Regular or Not/Last one) 2-Amount: How much do you take?
3-Home monitoring/Last reading. 3-Frequency: How often do you take them?
4-Diet Monitoring(+Weight changes) 4-Compliance: Do you take them regularly?
5- Current status(How do you feel today) 5-Side effects (Complications): Have you experienced
6-Complications: any side effects from the drugs? As The most
a-Visual(any problems) common side effects of this drug are:
numbness-sexual problems)
c-Renal(Urinary Q)
d-Vascular{Leg pain- Feet care(itching/
white spot)/Aneurysm ”SOB/CP”}
Fever:(When/How high/Did the fever Rash:(Describe it-itchy or not/analyze as pain)
disappear, only to reappear later) 1-Acne vulgaris
1-Infection&inflammatory disorders 2-Bacterial infection(Impetigo-folliculitis-Rosacea)
associated signs for every system. 3-Dermatitis(nummular-atopic)
2- Neoplasms (prolonged fever-night 4-Eczema.
sweats-wt loss-LAD-palpable masses) 5-Psoriasis
3-Thermoregulatory dysfunction(sudden 6-Drug-induced(anabolic steroids /androgens /
&high –anhydrosis-hot flushed skin-LOC bromides/ corticosteroids / dactinomycin/hormonal
decreased-low BP-Tachy”pnea/cardia” contraceptives/iodides / isoniazid /lithium
4-West Nile encephalitis(Headache-myalgia- /Phenobarbital/phenytoin / trimethadione)
rash-neck stiffness-low LOC) Itchy=Pruritis
5-Drug-induced started new(anticholinergics/ 1- Biliary disease(Jaundice/abd pain/fever-chills)
chemotherapy/ MAO inhibitors/toxic 2- Infestations: Pediculosis(Capitis-Pubis)
doses of salicylates or TCA 3- Fungal: Pitryasis rosea
6- Transfusion reactions 4- Scabies
7- IV drug abuse 5- Urticaria
8- Long steroid use (Suppress immune
9- Heat (exhaustion/stroke):did you go to
extreme temperature places?
========================= ===============================
Hoarsness of voice:
1-Laryngitis(Acute:URI or acute stress
/Chronic:chronic voice strain/Cig/EtoH)
2-Singer’s nodule
3-Laryngeal carcinoma
5- Retropharyngeal/ Peritonsillar abscess
Amenorrhoea:(Must ask about FMP) Vaginal bleeding:
1-Pregnancy(Have you missed a period/ 1-Dysfunctional uterine bleeding/Anovulation(Cycle Qs)
breast swelling or weight changes) 2- Hypothyroidism(Temp-Skin-Hair-Voice changes)
2- Hypothyroidism(Cold intolerance-skin & 3- Molar /Ectopic pregnancy
hair changes) 4- Spontaneous-septic abortion/Endometritis(fever)
3- Hyperprolactinemia(Breast discharge) 5- Atrophic vaginitis(Most cause in 80% -Mood swings
4- Polycystic ovary syndrome(Urinary/weight - hot flashes-discomfort during intercourse)
/excess hair/voice deepining) 6- Cervical (polyp/ laceration)(Persistent intermenstrual
5-Anxiety-induced amenorrhea(stress/ Eating postcoital bleeding &Pain+ Pink-foul smelling
& exercise habits)-sleep/constipation discharge),Back pain,leg swelling/UrineQ)
6- Pituitary tumor(Headache-vision) 7- Endometrial ( polyps/fibroid) (Postcoital or post
7- Ovarian or adrenal malignancy (hair thining douching bleeding that becomes heavier&
/Acne/excess hair/enlarged abdomen) frequent Clotting& Anemia)
8-Premature ovarian failure- Menopause (For 8-Cancer (Cervix-endometrium)
both:hot flashes=flushes=night sweats- 9-Coagulation disorders (VWD-hemophilia-hemolytics)-
vaginal dryness-bone problems) Brusies
Vaginal discharge: Dyspareunia(Pain during sex)
1-Bacterial vaginosis” Thin, green or grayish white, 1-Atrophic vaginitis(Bleeding-hot flashes-vaginal
foul-smelling discharge” dryness during sex - Thin, scant, watery white discharge)
2-Vaginitis(candidiasis” White, curdlike, profuse 2-Endometriosis(pain with “menses/defecation”)
discharge with yeasty, sweet odor”-trichomoniasis” 4-PID{Cervicitis(vaginal discharge-back or abd.
Frothy, greenish yellow, and profuse foul-smelling) pain-)/Acute salpingo-oophoritis/ Tubo-ovarian
3-Cervicitis (chlamydia” Yellow, mucopurulent, abscess (TOA)}-Fever/N,V
odorless, or acrid discharge”-gonorrhea” Yellow or 5- Vulvovaginitis
green, foul-smelling discharge ”) 6-Vaginismus(timing/ Anxiety /Hx of sexual abuse)
4-Foreign body (retained tampons, swabs) 7- Domestic abuse(feel safe at home)-very imp
5- Malignancy (cervical/endometrial) 8- Depression(sexual desire/conflicts with partner -
history of sexual trauma=abuse or rape)
The STDs: 9-Pelvic tumor(Pressure symptoms-urinary/abd Qs)
1-Trichomonas/Chlamydia Trachomatis
Urinary Incontinence: Positive pregnancy test:
1- Genuine Stress incontinence.(weak pelvic 1- Normal pregnancy(N/V, Fatigue, weight gain, and
muscles + Increased intra abd.Pressure breast engorgement& discharge, Urinary
,coughing-sneezing-standing-laughing) frequency).
2- Detrusor instability =Urge incontinence (did
you ever notice a sudden urge to 2-Ectopic pregnancy.(Be aware of Light vaginal
urinate immediately-frequent urination bleeding/ Lower abdominal pain/ Cramping on one
,pass large amounts- day& night) side of the pelvis/Dizzy)if any aggravates, call 911
3-Mixed incontinence(Do you wear
absorbent pads) 3-Molar pregnancy(severe nausea and vomiting,
4-Overflow incontinence(spinal cord injury/ new-onset hyperthyroidism, Anemia, High
trauma to back/DM)-dribbling BP,Vaginal discharge of grape-like cysts or Dark
5-UTI(burning urination – fever) brown to bright red vaginal bleeding during the
6-Atrophic vaginitis (Bleeding/ Hot flashes/ first trimester).
discomfort during intercourse/mood)
7- bladder cancer (weight changes-blood
in urine)
8-DM(excessive drinking/thirst)
9-Excessive caffeine or alcohol
In all pediatric cases, we will ask all System Qs and focus on the main complaint.
Child with fever Behavioral problems in childhood
1-Neonatal sepsis 1-Temper tantrum(breath holding spells –pass out –
2- Meningitis harm himself – parent’s response – seizure
3-Acute otitis media (Before& after the attack) – depression/autism
4-URI / Pneumonia 2-Attention-defi cit hyperactivity disorder (ADHD)(place of
5- Gastroenteritis (viral, bacterial, parasitic) attack / easy distractibility /hard time
6- UTI concentrating /memory status/problems organizing
7-Roseola infantum (Infant Measles) ideas/difficulty taking decisions)
8- Viral exanthema: Measles(Rubeola) 3-Oppositional defiant disorder
/Mumps(German measles) / Rubella 4-Conduct disorder(No sense of guilt-indifferent to
9- Fifth disease(Parvovirus B19 infection)= actions)
(“slapped cheek” appearance) 5-Adjustment disorder(stressful event)
10- Varicella(Chicken Pox Virus) 6-Substance (intoxication/abuse/dependence)
Child with diarrhea Epistaxis:(Analyze blood/Uni or Bilateral)
1-Viral diarrhea : Rotavirus 1-Trauma-fracture football)
2-Bacterial diarrhea (Shigella, Salmonella, 2-Foreign body/Nasal picking
Campylobacter jejuni, and Yersinia) 3-Allergic rhinitis
3-Malabsorption(Cystic fibrosis -Milk 4- Hereditary haemorrhagic telangiectasia (blood comes
intolerance)-abd distension/chest Qs out With sneezing/Blowing nose-in puberty)
4-UTI or Pyelonephritis. 5-Bleeding disorders=leukemia/aplastic anemia(Bruises/
5-Intussusception.(vomiting bile or faeces) fever/fatigue-body aches/recurrent infections)
6-Bacteremia/sepsis 6-Chronic intranasal drugs use (Cocaine=cardio Qs)
7-Nasal tumours (tired/loss weight)
8-Drug-induced (Aspirin-warfarin)
9-Chronic disease(uncontrolled HTN-Liver disease)
Child with constipation: Child with jaundice: (Stool+ Urine color)
1-Functional=1ry constipation(after 2 yrs) 1. Physiologic jaundice(age of child)
2- Hirshsprung diseae.(at birth-His 1st BM) 2. Breast-feeding jaundice(Timing & frequency)
3- Diet-induced constipation(diet analysis) 3. ABO or Rh incompatibility(Your own blood group and
4- Dehydration(enough water/milk) the blood groups of your husband and baby/ Other
5-Anal fissure(is there any cracked skin pregnancies and miscarriages before)
around anus/fear of using other Toilets) 4. Neonatal sepsis(TORCH) (Awake and responsive-
6- Hypothyroidism/DM. (Changes with his Sucking and cry-ill contacts-General Qs)very imp
skin/prolonged jaundice after birth / 5. Cephalohematoma
urinary changes) 6. Familial neonatal hyperbilirubinemia
7- Medication-induced constipation(iron/Ca) Late-onset neonatal jaundice (after one week):
8- Stress-induced constipation(new school or 1-Breast milk jaundice.
problems at home) 2-Biliary atresia.
3-Metabolic disorders: Hypothyroidism, Galactosemia,
or hereditary hemolytic disorders such as
Spherocytosis or G6PD deficiency
Child diagnosed with diabetes Child with Bed wetting
1. Type 1 DM 1.Monosymptomatic primary nocturnal enuresis.(Family
2. Type 2 DM problems/Stress/other children)
3. Secondary causes of diabetes (such as 2.Secondary enuresis:UTI/DM(dysuria-excessive fluids)
Cushing’s- cystic fibrosis, 4. Functional bladder disorder(Fx-any neurological
hemochromatosis and acromegaly) problems-shaking movements)
4.Prader-Willi Syndrome.(Obesity) 5.Sleep apnea/Sleep terror disorder(Wake up in night)
5.Maturity onset diabetes of youth. 6. Constipation(GIT Qs)
7.Congenital anomalies(ectopic urethral orifice)Fx
Child with noisy and strange Child not eating (Picky eater)-why do you think
breathing/Stridor: so/OCD/Frequency
1.Sudden(Foreign body aspiration) muffled cry 1-Habitual eating disorder(What is his/her favorite food
/Best heard on inhalation or exhaling air ? /How many meals/snacks does your child eat
2.Infection{Viral(Croup-Laryngitis- each day? Does he watch TV before mealtime?)
Bronchiolitis) or 2-Iron deficiency anaemia
Bacterial (Epiglottitis/tonsillitis/Pertussis) = 3-Lead poisoning(What kind of house/moving
drooling/ Blueness of skin} recently)
3. Retropharyngeal/ Peritonsillar abscess 4-Fiber-lack diet(GIT Q)
(Hoarsness of voice) 5- Parasitic Infections
4. Chronic (Laryngomalacia)=snore nightly 6- Depression(Social Qs-mood swings)
5-Asthma 7- Parental influence: Have you ever punished or
6. Angioedema. (Fx of allergies) rewarded him to change his/her eating behaviors?/
do you follow a set schedules of meals?/Do you
*Do you know anything which may have often offer dessert along with the routine meals)
caused it? 8-Slow growth rate(small stomach than others)
*Is s/he able to breath, cough or talk 9-Genetic: related to the number of taste buds
Child with Hematuria
1-Congenital anomalies(obstructive uropathy and renal dysplasia)=pregnancy& birth history
3-Polycystic kidney.
4-Hematologic disorders, ( vitamin K deficiency, hemophilia, and hemolytic uremic syndrome;
5-Tumors (Wilms’ tumor, bladder cancer, and rhabdomyosarcoma);
6-Allergies; foreign bodies in the urinary tract;

Important Investigations(All in brackets is single investigation)

Sepsis: (CBC with differential, blood culture, UA and urine culture)

(In Children) add Titers for CMV, toxoplasmosis, and rubella(If required)

Meningitis: (CBC, Electrolytes)-ESR-(LP,CSF analysis) / (CT head or MRI brain)

Sleep: Ambulatory nocturnal pulse oximetry – Polysomnography

Ear Infection: Audiometry- Tympanometry - Brain stem auditory evoked potentials –

Dix-Hallpike maneuver(BPPV) – (VDRL/RPR)
(In Children) Pneumatic otoscopy – Tympanometry

Eye Infection: Tonometry - Slit lamp examination-discharge culture

Sinusitis: CT sinus

Throat: (Throat swab for culture& ASOT) - (Monospot test & Anti-EBV Abs).

Thyroid: TSH / US

Chest: ABGs – CXR(PA and lateral) – CT chest– (Sputum exam”microscopy, Gram

stain, AFB smear, Culture, Cytology”) – PPD – Direct laryngoscopy(FB) –
Bronchoscopy with BAL (hemoptysis-cancer-ILD) - Spirometry
(Asthma/COPD/GBS/ Neuromuscular disorders)- PFTs
For PE: Doppler U/S legs – D-dimer
Heart: ECG – Stress test – ECHO(TEE/TTE) – Cardiac enzymes(CPK-MB, troponin)
- Cardiac catheterization(MI) +/- Cholesterol &TGs levels

Abdomen General: AXR - US–(CT abdomen& pelvis) –(Rectal exam, Anoscopy).

Esophagus& Stomach: 24 hour pH monitoring - Upper endoscopy
Noninvasive H. pylori testing=urea breath test ( for peptic ulcer disease)

Bowel: FOBT - (Stool leukocytes, culture, ova and parasitology,and pH )-

Electrolytes(Esp in diarrhea) – Colonoscopy - Procto-sigmoidoscopy
(In Children) Rotavirus enzyme immunoassay(imp.)

Liver: (AST,ALT,ALP,bilirubin )-Viral hepatitis serologies – (PT/PTT )-

(MRCP/ERCP)----(esp.for PSC)
(In Children) Blood type + Direct Coombs’ test

Pancreas: (Amylase, lipase) / D-xylose

DM: Serum glucose - (UA, urine microalbumin) –( HbA1c )- Islet cell Abs

Kidneys: UA/ Urine “culture-cytology” / (BUN,Cr) / US(main)/ Cystoscopy

Adrenal: Dexamethasone suppression test – 24h urine free cortisol/US

Genital organs: Urine hCG / “Genital or Pelvic or Breast” exam

*STDs: (Wet mount, KOH prep“whiff” test) / Cervical GC DNA testing/Pap
*PCO:(LH/FSH) – (Testosterone/DHEA)
*(Ectopic pregnancy –PID-Endometriosis -Pelvic cyst): Laparoscopy
*(Impotence) :Testosterone , prolactin level-TSH-Doppler US penis

Bone : X-Ray(AP&Lat)–DEXA scan(Osteoporosis)–Bone scan (Osteomylitis/Cancer)

–MRI(For ligaments &Tendon injuries)– PSA(For suspected mets.)

Rheumatology *(SLE/Rhematoid arthritis): (ANA, anti-ds DNA, RF, ESR )

*(For Gout/ Pseudogout /Septic arthritis): Arthrocentesis and synovial fluid
analysis(cell count, culture, crystals , Gram stain)

Myositis (Aldolase, CPK), Muscle biopsy

{In Neuropathy-Weakness}: anti-acetylcholine receptor antibodies,
(EMG/Nerve conduction studies)
Dermatology: (Fungal) Wood’s light – Fungal culture
(Allergy) Patch test (Any colored lesion ):Skin biopsy

Anaemia: (CBC with differential) – (Serum iron level, TIBC, ferritin,B12 level)

Pyschiatry: Mental status exam - Urine toxicology – TSH – (CBC ,Electrolytes, calcium,
glucose) - BUN/Cr
Drug abuse Urine toxicology - Mental Status Exam

AIDS: HIV antibody and viral load

Abuse: Skeletal survey