HPI (history of present illness) ALL CASES: OPD CSF AAA PAIN: OPD CSF LIQR AAA OPD CSF ABCDO FLUIDS: (Vomiting, Diarrhea, constipation, cough, vaginal discharge) O Onset of the symptom + precipitating factors P Progression D Duration C Constant /Intermittent S Settings F Frequency L Location of the symptom (forehead, wrist… ) I Intensity of the symptom (scale 1-10, 6/10) Q Quality of symptom..
BCDSPP(burning,Cramping,dull,Sharp,pulsating,pressure like) R Radiation of the symptom ( to left shoulder and arm) A Associated symptoms ( palpitations, shortness of breath) A Alleviating factors (sitting with my chest on my knees) A Aggravating factors (effort, smoking, large meals) A Amount B Blood C Color C Consistency C Content D Duration O Odor UG Hx: OPD-CSF-AAA + FINISH PUBC F Frequency (How frequent do u have to pass urine? ) I Incontinence (Do u have trouble holding Ux until u get to BR? ) N Nocturia ( do u have 2 wake up @ Night to go to BR?)
I Incomplete emptying (do u feel fullness even after Ux) S Stream (How is ur flow of urine? is it cont. or is there any dribbling after Ux? ) Strain (Do u have to strain during Ux) Stone (have u passed stones in the past? ) H Hematuria (did u notice any blood), Hesitancy (do u have 2 wait b4 starting Ux) P Pyuria (was there any pus in ur Ux? ) U Urgency (do u have 2 rush to BR to Ux? ) B Burning (dysuria) (does it burn) C COLOR 1 drkhalilezekiel@yahoo. com PMH (past medical history) PAM HUGS FOSS P Previous presence of the symptom (same CC), Past Medical problems (^BP, ^BS,U , idney prob., Rhinitis,Sinusitis, sthma,) A Allergies (drugs, foods, chemicals, dust … )
M Medicines (R U taking any prescription medications/any over-the-counter med. ), H Hospitalization for any illness in the past (Trauma, surgery) U Urinary changes ( esp if diabetic, elderly… ) G Gastrointestinal complains (diet changes, bowel movements… ) S Sleep pattern(difficulties falling/maintain asleep,wake up,snoring,med. to help sleep, how many hour, nightmares) F Family history (similar chief complaints/serious illness)/ Fevers, Chills/ Fatigue O OB/GYN history (LMP, abortions, para…
) LMP RTV CS PAP S Sexual habits (active/preferences/STD/no. of partners/contraception/pregnancy/ last pap smear) Q 1. “Mr. John, Are you Sexually Active? ” Q 2. “How Many Partners are you active with? ” Q 3. “Are your partners male or female or both? ” [Unless the SP says wife or husband in Q 2] Q 4. “Do you use protection during intercourse? ” Q 5. If yes in Q. 4 “What kind of protection do you use? ” Q 6. Ask about anal intercourse in male homosexuals Q 7. h/o STD’s; Rx for STD’s S Social Hx (job/house/smoking/alcohol/recreational drugs/….. ) WAD SAD TOES Social Hx WAD SAD TOES.
W Weight A Appetite D Diet S Smoke (cigarettes, marijuana, how much, how many years) A Alcohol (what type of alcohol, how often, how much ,consider doing CAGE question. ) D recreational Drugs (what drug, how do you use it, any IV drug use? ) T Travel /Trauma O Occupation (what do you do for living? ) E Exercise S Stress HEADACHE OPD CSF LIQRAA + DIAGRAM Head trauma/Seizure/Weak,Numb Tears / visual changes Flu Vomit/ Speech Neck stiffness 2 drkhalilezekiel@yahoo. com Ped Hx (Child with fever) CUB FEVERS + PAM IF BIG DEALS-T C Colds-runny nose,cough,chest pain, fast respirations,SOB-CRY“how is ‘cry of ‘baby?
” U Urination-increased or decreased urination, # of diapers, any odour, colour of urine Ulcers in mouth B Bowel changes: Diarrhea-frequency, onset, mucus/pus/blood in stool, any crying during defecation Discharge Q’s (ABCD-O: Amount, Blood, Content, Consistency, Color, Constant/Intermittent, Duration, Odor/Onset) F Fever & chills E Ear pulling V Vomiting E Ear/eye discharge, Ear hearing, Eye vision R Rash S Seizure-any jerky movements, which part of body? Any leakage of urine or stool during fits, and postictal irritability or loss of consciousness. Stress (bet wet, DM) P Past medical/Past surgical Hx / Previous Hospitalizations.
A Allergies, effect on child/parents (bet wet, DM), Activities M Medications, Menstruating (female child >10yo) I Ill contacts F family history B Birth Hx I Immunizations G Growth n development, ht, wt, milestones SSC-WTD: S(1), S(6),C(9),W(12),T(15), D(30) smile, sit, crawl, walk, talk, dress wks: 1,6,9,12,15,30 D Day care / Difficult swallowing E Eating habits, feeding of baby A Appetite L Look of the baby or appearance, Last check-up S Sleep T Travel recently Premenopause : H Hot flashes A Atrophy of vagina D Dryness of vagina O Osteoporosis (council) C Coronary artery disease HADOC.
3 drkhalilezekiel@yahoo. com ObGyn Hx : LMP RTV CS PAP L LMP (when was ur LMP? ) M Menarchae (how old were u when u had ur 1st period? P Period (how many days ur period last? ) R Reglarity ( R ur periods regular? ) T Tampoons (how many pads do u use in a heavy day? ) V Vaginal DID: discharge, itching , dryness (have u ever had any vag discharge? ABCDO. do u have any vag. Itching? ) C Cramps (Dysmenorrhea) do u have abd cramp with ur period? S Spotting ( intermenstrual / post coital ) have u ever bled (. ) ur cycles?
Did u ever notice any bleeding after intercourse? P Pregnency ( Hx & complications) have u ever been pregnant? How many times? A Abortion/miscarriage (Any miscarriages or abortions? In ? month of ur pregnancy? ) P PAP smear(have u been getting regular PAP sm ? when did u have the last PAP sm ) (any Female>50 yo:ask about:1-R u taking vit D & Ca,2-have u ever tried HRT? ) If suspect abuse SAFE GARDS S Safety inquiry (Do you feel safe at home? ), Sex ever forced? A Alcohol abuse (does your hubby abuses alchol? ), Attacked Children? F Friends/.
Family who are aware( Dos any1 f ur friend/Fam know of this) Fractures (Abuse ever resulted in fractures? ) E Emergency plan (u have emergency plan? ), Ever tried to leave/divorce? why not? G Guns at home (are there any weapons @ home? Attacked with it? ) A Afraid of husband R Relationships with husband (how is ur relationship with husband? do you feel Threatened when he is around? For how long? D Depression (lost wt/appetite/sleep), Drugs (does husband use recreational drugs) S Suicidal (idea/plan/attempt) (ever felt like ending it all up? ) 4.
drkhalilezekiel@yahoo. com Diabetic pt “FU/Med Refill” D Duration of disease I Insulin regimen/ oral hypoglyemics regimen A A1c hg -> Gluc. monitoring (fast, home, HgA1c) B Blurry vision (retinopathy) E Extremity (foot ulcer/infection T Tingling/numbness (neuropathy) I Infections (resp/urinary) C Cardio Risk Factors (HTN, CHOL, Heart disease) Counseling DM & HTN M Medications (regularity) E Exercise ( for obese/sedentary life styles) D Diet Modification( Salt/Fatty foods) O Opthalmoscopic exams (annual routine) W Weight Management (/control) S Sugar Check ups.
DIABETIC MEDOWS Neuro cases “LOC” P Palpitations A Aura “b4 problem” S Shaking (duration) S Spinning/ lightheaded B Bladder incontinence / Bowel incontinence L Loss of consciousness (duration) T Tongue biting/ tinnitus & hearing loss S Speech difficulties/ Sleep disturbance A Ataxia “gait” N Numbness/nausea & vomit D Difficulty breathing W Weakness I Injury (trauma) & fall C Confusion after the event / Visual disturbance H Headache PASS BLT SANDWICH -And to make sure you got it completely don’t forget the MinMental Stat.
Exam 5 drkhalilezekiel@yahoo. com MINI MENTAL O Orientation X3 “ time, place, persons” R Registration “I’m going to say 3 objects”… then repeat A Attention “spell world backwards” R Recall what were those 3 items again? L Language “Repeat after me.. “No, ifs, ands, or buts” 2 Identify two objects “what is this.. pen.. and this… paper” 3 Obey 3 commands “take a piece of paper, fold in ? , put on floor” R “Read 3 commands on this paper and do what it says” W Write a sentence D Draw, copy the image ORARL23RWD.
Forgetfulness/ Memory Loss / Dementia/ Alzheimer’s FORGETS HIM + DEATH SHAFT F FAINTING / Flashes/ FHx of Alzheimer 0 ORTHOSTATIC HYPOTENSION R RUNNING URINE “INCONTINENCE” G GAIT E EYE[VISION] T TRAUMA, TINGLING S STRENGTH,SEIZURES H HEADACHE I INFECTION [SYPHILIS, MENINGITIS] M MOOD ADL – Activities of daily living D Dressing E Eating A Ambulation (can you find your way thru home) T Toiletry (do you manage your toiletry unassisted) H Hygiene IADL – Instrumental activities of daily living S Shopping H Housekeeping A Accounting F Food prep (do u do your cooking ).
T Transportation (do you drive? How is your sight, hearing?) 6 drkhalilezekiel@yahoo. com Foot / Heel / Knee / Back pain OPD-CSF-LIQORAAA +WET SURF-D -‘CIS’ W Work /Weakness / Walking habits /Wt loss E Eye infection redness T Trauma to foot /Tingling& Numbness / Tender S Stifness in other joints/leg Swelling /long Standing hours/morning Stiff/sound U Urethral discharge /ulcer R Rash/ Redness of skin of joint F Fever & chills& night sweat D Deformity / Dysurea IN CASE OF BACK PAIN ADD: CIS; Cancer Hx /IV DRUGS/ Steroids 4 long time Depression: (Psychiatric Hx Checklist) SIGME CAPS DHAT +2 (+MMSE: ORAL23RWD).
S Sleep (difficulties falling/maintain asleep, wake up, snoring, med.to help sleep, how many hours, nightmares), Stress, Support I Interest, What do you do in your free time? How are you doing in your job? do you enjoy what you do? G Guilty M Mood. ( anxious, sad, hopeless, lonely? Memory problems E Energy C Concentration A Appetite, changes in your Weight P Psychomotor agitation/retardation (do you feel easily agitated or angry/do u feel not to do anything? ) S Suicide: thoughts, plan, attempts(do u have pills/guns @ home?)
D Delusions/Drugs H Hallucinations/Hopes A Attitude towards life (positive negative frame of mind) T Thyroid dysfunctions (ABCD HV for HYPOTHYROID) also need to ask : Do u realize that u have problem ? Do u want help? ( if patient was sent or asked by anyone to consult doc ) HYPOTHYROID APPETITE BOWEL-constipation COLD INTOLERANCE DEPRESSION HAIR FALL VOICE-Hoarseness 7 drkhalilezekiel@yahoo. com ABCD HV Hearing loss: P Pain D Discharge F FB I Imbalance N Noise R Ringing S Spinning T Trauma Dx ABD Signs PDF IN RST CKMG MIOR (MIOR assoc. with Appendicitis)
C Cullen $- periumbilical discoloration (Retroperitoneal He,pancreatitis, AAA rupture) K Kehr $ –sever Lt. Shoulder pain- Splenic rupture, ectopic pregnancy M Muphy’s $- Abrupt interruption of inspiration on palp of RUQ- acute cholecystitis G Gray-Turner $, Discoloration of flank (same as Cullen $) M Mc Burney’s $- Tenderness 2/3 from ASIS to Rt of umbilicus I Iliopsoas $, Hyperextention of R hip Cx ABD pain O Obturator $- Internal rotation of flexed R hip Cx ABD pain R Rovsing $- RLQ pain upon palpation of LLQ DD Nasuea & Vomiting A Anorexia M Metabolic( DKA)/Meds O Obstruction (pyloric/Intestinal) P Pregnancy I Inflammation( Pyelo/Cholecysto/Appi/Pancreas/PID)
N Neurological (BETA)= Bleed/Encephalitis/Tumor/Abscess G Gastroenteritis A MOPING 8 drkhalilezekiel@yahoo. com Cranial Nerves: 2 optic 3 4 6 5 7 Oculomotor Trochlear Abducent Trigeminal -Test visual acuity -Test pupillary reflexes (direct&consensual) -Test accommodation reflexes -Assess pupillary reactions to light -Assess corneal reflection -Perform H-test for EOM -Sensory: close eyes,touch face&ask where?
-Motor: Assess strength of muscles of mastication;bite down and palpate masseter Ask patient to; -smile -wrinkle forehead, -blow out cheeks -close eyes -whisper, -Weber -Rinne tests Assess movements of the soft palate; swallow and palpate neck Assess strength of trapezius & sternocleidomastoid muscles; -shrug shoulders up -move neck to side against resistance Ask patient to protrude tongue (assess for fasciculation, atrophy & Deviations) -stick your tongue up -move it side to side facial 8 Vestibulocochlear 10 vagus 11 accessory 12 hypoglossal 9 drkhalilezekiel@yahoo. com – Mr. ?
– Good morning Mr., I am Dr. Khalil, an attending physician in this hospital. SHAKE HANDS First I’ll ask u few Qs. and do brief physical exam. Meanwhile if u have any Qs, feel free to ask me, ok? – Let me make u more comfortable DRAP PT. – I’ll be sitting & writing some notes while we’re talking, is that ok? …THANK U. – Please tell me what brought u in today Mr. ? …….. – I. C. , can u tell me more about …….. “c. c. ” Mr. I’d like to ask u few Qs. about ur health in the past, is that ok? Mr. now I’d like to ask u few Qs. about ur habits, is that ok? Now I’d like to ask u few personal Qs. I assure u that all info.
Will be kept confed. ok? Now, let me ask u few Qs. about health of your family members, ok? Does any body in ur family have any med. Conditions? Mr. thank u. I am done e history, let me summarize for it, As u mentioned, u have ….. Do u have any Qs. for me? Mr. Now I need to examine u. may I proceed? But 1st let me wash my hands. Ok? Mr. Thank u for ur cooperation. I am done e phys. Exam let me give my impression. Based on ur Hx & my PE, it seems that u might have….. but it could be something else/ …or…, so to arrive at right D, I ‘ll run some tests & order imaging studies such as …..once I’ve result we’ll meet again discuss various ttt.
ptions. – Do u have any Qs. for me? SHAKE HANDS & LEAVE ROOM 10 drkhalilezekiel@yahoo. com HISTORY HPI: OB/GYN: LMP…, regular periods every….. Weeks ,lasting….. Days. Menarche at age… Uncomplicated NSVD at full term.. Years ago. ROS: negative except as above. Allergies: NKDA Medications: none PMH: PSH: SH: smoke /alcohol / illicit drugs/sex / job /exercise FH: noncontributory PHYSICAL EXAM Patient is in no acute distress OR looks .. (anxious,tired, …)
( The source of information is the patient’s mother. the mother of a ….-month/year-old female/male c/o her child having ….. ) VS: WNL (except for temp. Of …) HEENT: NC/AT, PERRLA, no conjunctival pallor. No fundoscopic abnormalities. Nose,mouth and pharynx WNL Neck: Supple, No LAD, thyroid normal, no carotid bruits. Chest: no tenderness, clear breath sounds bilaterally. Heart: RRR, normal S1/S2, no murmurs, rubs or gallops Abdomen: soft, non-tender, non-distended, +BS, no guarding, no hepatosplenomegally Extremities: no edema, normal DTR in lower extremities Skin: no rash Neuro:
MMSE: AOx3, spells backward, recalls 3 objects, Cranial nerves: 2-12 grossly intact, Motor: strength 5/5 throughout -sensory: intact to soft touch and pinprick, DTR: symmetric 2+ in all extremities (or lower extremities), – Babinski bilateral, Gait: normal, Cerebellar: – Romberg, rapid alternating movement and heel to chin test normal and symmetric 11 drkhalilezekiel@yahoo. com UWShort UWLong 1 16-31-37 2 1-13-1925-35-39 24 25 4-5-1822-24 29 15 28 20 21-40 12 7 43 10 FA Full 19 1-2 38 6 3 FA Mini CASE 23-24 Urine problem Alcoholism 19 Abd pain Heel pain Chest pain 13 8 31 5 6 7 4 6-26 9 10 38 42 34 11.
UL pain 31 Shoulder pain 21 Knee pain 27 32 Back pain 37 Calf pain Vomiting “adult” 18 Vomiting “child-TEL” 7-8 33 Fever “child” 5-28 20-22 Diarrhea Rectal bleeding Constipation 9 Night sweat 21 Hemoptysis 9-10-40 12 Chronic cough 15-16-17 8 Fatigue 15 Wt loss 16 Wt gain 17 dysphagia 18 1 Headache 3 Depression 4 psychosis Anxiety Seizure –new onset Amenorrhea Menopause 25 26 Menstrual problems 26 Vaginal discharge 12 drkhalilezekiel@yahoo. com 12 23 13 30 9 33 14 16 17 18 19 20 21 22 23 12 36 13 27 23 6 2 22 41 30 36 41 3 17 32 34 14 11 39 30 14 15 30 10 5 7 26 27 28 14 8 32 27 29 11 2 drkhalilezekiel@yahoo. com 35 33 26 31 4 29 29 11 25 34 Forgetfulness Frequent falls DM New DM drug refill BA drug refill HTN drug refill HIV drug refill Vaginal bleeding Obesity Spells “LOC”.
Terminal cancer Confusion Tremors Pre-employment Domestic violence Sexual assault Insomnia Dizziness Numbness-weakness Jaundice “adult” Jaundice “Neonate” Enuresis Palpitations SOB Smoking cessation Hallucinations +ve Pregnancy test Pain with sex MVA Sore throat Difficult swallowing Hearing loss Blurred vision Erectile dysfunction Behavioral problem “child” Skin rash
13 FA cases GIT Trauma Resp Cardio Ped Neuro Endo Psych Renal ObGyn Pain DM/HTN Jaundice Fever Fatigue 1-2-5-11 3-21-27-31-37-38 4-9-10-41 6-20 7-8-28-30-36-39-40 12-14-18-22-23-29 13-24 15-16-17-34-35 19 25-26-32-33 FA cases 1-2-3-21-38-6-27-37 13-20-36 11-39 7-8 15-16-17 14 drkhalilezekiel@yahoo. com.