Introducing Your Self:
Knock the door before entering. Wait for a while and then slightly open the door and call the patient by last name
Mr. / Ms. Smith! Hello! I am Dr Chebli, I will be your physician today (Shake hands with the patient and look into SP eyes), nice to meet you! I will ask you some questions and do a physical exam on you, is that fine with you?
Let me cover you up”…and while saying so, DRAPE the patient’s legs up to his belly. Then, “So Mr. / Ms Smith, what made you come in today?”
After SP tells you the CC and stops, first EXPRESS SYMPATHY- say, “Oh I am sorry to hear that, I shall try my level best to help you. I hope you do not mind if I write down a few notes while we talk”.
Are there any other concerns that you have? If yes, then ask:”Anything else?
If multiple problems, then ask:” As you have a number of concerns, what seems more important to you?”
Please tell me more about it from the beginning?
What made you decide to get it checked now?
SP in pain, your answer:” Is there anything I can do to help you feel more comfortable right now?”

Pt in great pain:
Ms. Kenfack, I am Dr Chebli, I will be your physician today. I can see you are really suffering. I am here to help you.
I’ll just need to ask you a few questions and do a quick physical exam in order to know what is bothering you. Is that OK with you?
To make you a little more comfortable, let me cover you up.
Is there anything I can do to help you feel more comfortable right now?
Can you please tell me more about what is bothering you?

Silent Pt:
Ms. Kenfack, Hello I am Dr Chebli, I am the phys on duty here today. Ms. Kenfack, I know life can be stressful and even may be hard to come and see a doctor. Take your time; I am here to help you.
Go get napkins and give to the patient. Wait three seconds
I can help you better by asking some question, do u want talk about what is making you sad?

Important Notes:
Don’t raise eye brows or frown.
It is not necessary to respond after each & every answer.
Avoid phrases or words like “Good”. A simple “Thank you” or “Okay” is often sufficient.
Reserve all the patient education for very end of encounter. [This is controversial; some do counseling during history taking. I believe do what makes you more natural and comfortable during the exam. ]
Let the patient know that you are going to untie the gown or move the drape
Replace the drape without delay when u have done specific region examination
Patient should not feel rushed. Quietly wait for the patient to complete each answer. Don’t fill in words for the patient; the answer should be in his or her own words.
Remain connected and purposeful during physical examination
DO NOT shake hands if pt lying down in pain or shoulder pain
DO NOT say the diagnosis first thinking that you can explain it after...SP jump and say what is that?
DO NOT SAY trauma...say accident
DO NOT SAY ...I don’t know....say I do not know YET
DO NOT ignore pt efforts to take care of his health....congratulate him
DO NOT RUSH during the first 1 or 2 minutes,....take time so SP adapt to you
DO NOT give your back while washing hands
DO NOT stay stand up if pt is laying down,...is better if you seat and your eyes are same level to pt.
DO NOT forget to reassure and use the word.....let me assure you....
DO NOT move the pt unnecessarily...or too much
DO NOT write the chief complain in medical terms
DO NOT forget to say....DID that answer your question...do you have another question
DO NOT forget to paraphrasing
DO NOT put the pen in your mouth......careful if u have this tendency
DO NOT use leading questions
DO NOT repeat questions
DO NOT sound like robot
DO NOT say ok to everything....are your parents alive? No my dad has cancer....OK
DO NOT be afraid to make the pt repeat if he said something that you could not understood
DO NOT forget about the impact of the illness in his personal life

Social History: Now I will ask you a few questions about your lifestyle and personal habits.
Family history: “I’ll ask you some questions about your family history”
Sexual History: “I’ll ask you some questions about your sexual health and practice. OR sexual activities
Gynecological History: I will ask a few questions about female health.

Summarize: To summarize your history, you just told me that you have -------so and so ----- and you also said that so and so ------, is that right”
Is there anything you would like to tell me or add before I start your physical examination?
OR “Is there anything else at all you would like to bring up?

PHYSICAL EXAMINATION

Transitioning to a hand wash and physical exam:
Alright, then, I’ll perform a quick physical examination and then look at your (heart, lung, abdomen etc.., is this okay with you? (Yes). Thank you.
Excuse me for a moment here to put the gloves on OR ”to wash my hands” … “SMILE .
I will keep you informed throughout the physical examination. Do you have any special concern for now?

Physical Exam:
Remain polite and explain what you are going to do and say “thank you” each time you elicit a sign ( for e.g.: I need to check your neck, so if you could swallow for me please? Thank you.
When you make the patient lie down ask him: Are you comfortable?
When you do that please pull the extension out (foot rest)
Don’t touch the patient b4 giving instruction
Keep talking during the examination. Let the SP know what you are looking for.
When you elicit pain. Say I am sorry
Always maintain eye contact when you elicit pain and when you explain what you are going to do
Begin exam in logical manner from head to feet
Listen NOT Auscultate Tap NOT Percuss Press NOT palpate Belly/stomach not Abdomen
Mnemonic for GE: PICKLE- Pallor, Icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy, and Edema feet” along with Jugular veins, carotid bruit if a CV case
Let us start with your eyes, could you please look up for me
Head - Let me look at your head for any swelling, scar or any visible abnormality.

Face – Now I will press on various parts of your face for any areas of pain or swelling (tenderness, edema) please let me know if it hurts.

Ear – Now I will look inside your ear)

Nose – Let me see in your nose for any swelling, discharge or deformity. (discharge, deformity)

Mouth – Could you please open your mouth? Say ghaghaha, lalalaah., stick your tongue aout side and move it from side to side You may close your mouth now. Thank you

Neck – Let me check your neck any swollen glands (lymphadenopathy and thyroid. Could u please swallow for me? Thank you

Hands – Let me look at your hands.

Legs – Now let me check your legs for pulse and swelling, for that I might need to raise your gown, is that okay with you? (Edema, pulsation). Thank you. Let me cover it again.

Respiratory system:
Mr. Smith now I’ll examine your chest. Could you please pull down your gown? Let me help. (Pt – it’s okay) You – thank you
Palpation- I’ll press on your chest, please let me know if it hurts?
Can you please take few deep nice breaths for me.
TVF – Can you please say 99 for me?
Percussion- Now I’ll tap on your chest. Let me know if it hurts.
Auscultation-Now, I’ll listen to your lungs. Can you please take couple of nice deep breaths for me? (Auscultate for full inspiration and expiration)
Bronchophony - Can you say 99 repeatedly for me please?

CVS
Right side, 3 positions

Now Mr. Smith I’ll examine your hearts in sitting and then lying down positions.
(check radial, dorsalis pedis, carotid pulse, and carotid bruit in general examination)

Inspection
Now I’ll examine your heart in lying down position. Please lie down for me. Let me help you in that……….thank you. Let me pull out leg extension to make you little more comfortable. (Sounds good?)
Now I am looking at your neck for any visible pulsation. Now I am looking to your heart for your heart beats.

Palpation
Now I am touching your chest to feel your heart beats. (thrill, PMI, heave, - note site, location and quality of impulse)

Auscultation
Mr. Smith, now I’ll listen to your heart. Could you please hold your breath for a few seconds? Auscultate 4 areas
Mr. Smith, Could you please turn to your left side for me? Thanks
Mr. Smith, could you please sit again for me? Thanks. Auscultate 4 areas
Mr. Smith, could you please lean forward for me? Thanks. Auscultate 4 areas. You can now tie it back- thank you Let me help

Abdomen
Mr. Smith Now I’ll examine your belly/stomach. For that I need you to lie down. Let me help you in that (remember to pull out the foot rest). Thank you. Could you please raise your gown up?

Auscultation
I’ll listen to your bowel sounds and blood vessels (bell – peristalsis, bruit of abdominal, renal, iliac artery)

Percussion
Now I’ll tap on different part of your belly. Please let me know if it hurts.

Palpation
Now Mr. Smith I am going to press your belly first lightly and then deeply, please let me know if it hurts. (Liver-press, gall bladder – hook finger (Murphy) , Abdominal aorta aneurism, Spleen)

Rebound tenderness – Now I’ll press in & release. Please let me know if it hurts when I press in or when I let go (release)- peritonitis

Appendicitis
Psoas’ sign – Now I’ll check for your appendix infection, for that could you please turn to your left side. Thank you. I am going to pull your left thigh to your back side. Please let me know if it hurts. (Left lateral position, right leg extension, and pain in RIF)

Obturator sign – I’ll bend your knee and hip. Please let me know if it hurts. (Flex right hip & knee then internal rotation at hip)

Rovsing sign – Now I’ll press deeply. Please tell me if it hurts. If yes, where did it hurt? (press in LIF – pain in RIF)

CNS
MMSE (3Q-time,place,person, 3-words-recent/intermediate/remote, 3-command,3-misc)

Okay, Mr. Smith now I will ask you a few routine questions, which I ask all my patinets
I’ll test first your orientation: 1) Where are you now? 2) Which year is it? 3) Who is the president of the US?
Now, I’ll check your memory. See FA for the detail of MMSE
Cranial nerves
Now I’ll check your brain nerve functions

II (optic) – Please cover your Right (then left) eye, Can you please count my fingers? Confrontation (visual field method – finger movements), pupilary light reflex (dim light, direct pt to look far on wall, shine light obliquely on each pupil)

III (oculomotor), IV (trochlear), VI (abducent) – H & X (follow the finger movement without moving head) , convergence (follow the finger movement)

V (trigeminal) – Motor – Please clench your teeth for me. Palpate the masseter muscle

Sensory – sharp dull sensation on 6 face areas(forehead, cheek, jaw)with closed eyes

VII (facial) – Can you please smile / raise your eyebrowe? Close your both eyes. I will try to open it up. Please don’t let me open

VIII (acoustic) – finger rubbing, weber, rinne ( if indicated)

X (vagus) – Ask the patient to swallow saliva (already done for thyroid)

XI (spinal accessory nerve) – Can you please shrug your shoulder (against resistant) for me, Please turn your head toward right (press from left) and vice versa

XII (Hypoglossal) – Can you stick out your tongue and move side by side?

MOTOR:
Power
1. - no movement at all
2. –Some flickering
3. – Movements but not against gravity
4. –Movements against gravity
5. – Movements against gravity against some resistance
6. – Movements against gravity against full resistance

Upper limb
(Flexion–at wrist, elbow & Abduction at Shoulder, Extension–at wrist, elbow & Adduction at Shoulder)

Hand – Can you spread out your fingers? Please hold my fingers as tight as possible & don’t let them go. Thank you.

Wrist – Please, push up? Can you push down? Thank you.

Elbow – Can you please pull in? push out? Thank you.

Shoulder – Can you push out? Can you pull in? Thank you.

Lower limb
Hip – Can you push up / push down your thigh? Thank you.
Knee – Can you kick out / pull in your leg? Thank you.
Foot – Can press on the gas pedal? OR can you pull up / push down your foot? Thank you.

Reflex –
I would like to check your jerks. First let me begin with your arms. Can you please clench your teeth for me? Biceps, Triceps and Brachioredialis ( if UL case, otherwise you can exempt it), Knee, Ankle. Let patient know what you are going to do next.

Babinski -Now I’ll stroke at your sole

Sensory- Now I would like to check your sensation in different part of your body. I will start with….

This is dull and this is sharp. Now close your eye and tell me which is what?

Position sense-Grasp big toe and show the pt ‘up and down’ now tell pt to close your eye and identify position of toe.

Vibration sense-

Two point discrimination-

Cerebellar test- now I’ll check your balance and movements.

Finger nose test – please touch your nose and then my finger by your finger repeatedly

Rapid alternate pronation and supination of hand – please do like this,

Now for balance test I need you to step down for few moments. Would you please? Yes, Thank you let me pull out step for you so that you can climb down of table.
Gait - Can you please walk across the room, turn around and come back? Can you please walk in a straight line for me?

Romberg test – please stand up with yours feet together and hands apart and close your eyes. Mr. Smith please be assured that I will not let you fall down ( ask pt to stand with your both feet together and close your eye for 5 second without support-test for sensory ataxia),

Spine

Now Mr. Smith, can you bend your back forward facing the floor. Please try to touch your toes by your hands. Ok, now can you bend backward facing the ceiling?
Special test-

Kerning’s sign-flex both knee and hip, then try to extend the knee only?
Now I am going to move your thigh and knee joint and will resume again It’s normal position

Brudzinski’s sign- When you flex the neck, there may be flexion of hip and knees
Now I am going to bend your neck to try to touch your chest.
(Patient resisting for physical examination: Mr. Smith, I can understand your feelings but to clearly understand your disease I have to do this examination. It won’t take more than a minute. Don’t worry I am here to assist you. I will inform you whatever I am going to do.)

Last Minutes:
All right, Mr. Smith, thank you very much for your kind co-operation. Now I would like to sit down and talk over what I think so far.
Ms. ______ your symptoms may be due to a problem with your (GI, Urinary system, Nervous, heart, lung) system, such as an ……… or ……………They might also result from a …………………. Another possibility might be an ……………………
In order to confirm the diagnosis and to rule out more serious illness, we will need to run some test, including a blood test to check the function of your (liver, ling, GI, glucose etc..) and urinanalysis, and a possibly a CT scan of your (head, abdomen, lung, etc..)
 Endoscopy: which involves examining your stomach by means of an optical instrument passed through your mouth
 CT scan: which is a special x rays that produces precise cross-sectional images of anatomical structure
 MRI: which is a non-invasive way to take pictures of the body by using powerful magnets and radio waves instead of radiation
 Echo or Doppler: sound wave pictures
 Colonoscopy: which involves looking at your colon through a thin tube that is mounted with a camera

I will also need to perform a rectal , pelvic, and/or breast exam.
After we get the results of those tests, we will meet again to discuss them in detail along with the final diagnosis and the treatment plan. [from FA]
As soon as I get the results, let us meet again to go over everything. At that time I will explain the details and we will talk about your options for treatment? Does this sound OK? [ from UW]

In case of telephone case: (severe dehydration d/t diarrhea)
Ms. …..from the information you have given me, I am concerned that your child may be dehydrated. She has not urinated since yesterday, and she is weak and drowsy.
It is very hard for me to assess her/him without seeing her, and I do not want to jeopardize her health in any way. For this reason, I am going to ask you to bring him/her in for a physical exam and a full assessment, and we will then proceed according to what we find on the exam.

Counseling:
If patient smokes, drinks alcohol, uses recreational drugs:
 Mr. Xyz, I have noticed that you use/drink_____. Are you willing to quit? Using this ___ can lead to a variety of a medical problems, including _____. If you need any more help from me, just let me know. I’ll be glad to help you.

Smoking :
 “Well, I strongly recommend that you quit smoking. Smoking is a major cause of cancer and heart disease. Are you interested in trying to quit now?
 SP: Yes
 Dr: I would be happy to help you quit smoking. We have many tools to help you do that, and I will be with you every step of the way. Let’s set up an appointment for two weeks from today, and we can get started on it then. Is that okay with you?

 SP: NO
 Dr: I understand that you are not ready to quit smoking yet, but I want to assure you that whenever you are ready, I will be here to help you.

 Another easy way to counsel:
Since cigarette smoking is associated with a variety of diseases, I would advise you to quit smoking; we have many ways to help you if you are interested.

Safe Sex: I would also recommend that you use a condom every time you have intercourse in order to prevent sexual transmitted disease (STDs), including HIV, to avoid unwanted pregnancy (in case of a female)

We can have you meet with our social worker to discuss social situation, and she can offer you a variety of resources.

If it is a psychiatric case, like depression, grief, anxiety, or dementia, ask this question:
Ms. Xyz, would you be willing to talk to a counselor or go to a support group?

Elder person/aged lives alone: Always ask if there is:
 Someone to take care of him or her. If NOT, ask if he/she
 Would like to join an APARTMENT COMPLEX FOR ELDERLY.
 Make sure u have proper facial expression not a blank face when saying all these. Forget that he is an SP and treat him like your mom or dad. You will pass easily.

Elder person lives with his son, a suspect victim of abuse:
 Mr. Xyz your safety is my primary concern, and I am here to offer you help and support whenever you need it.
 Sometimes living with a family can be stressful for the whole household. Have you ever considered moving to an assisted-living community or to an apartment complex for seniors?
 I f you are interested, I can arrange a meeting with our social worker, who can assess your social situation and help you find the resources you need.

A woman who is a victim of abuse:
 “Your safety is my primary concern, and I am here to offer you help and support whenever you need it.
 Every thing we discussed is confidential, but I must involve child protective service if your children are being abused.
 I have you talk to our social worker who will provide you with a variety of resources that can help you.
 It is very imperative that you have a safety plan.

Mr. xyz have you understood everything we have discussed today?
Do you have any concerns or question you’d like ask me before I go?
I understand that you must be worried about your condition. I want to reassure you that I will do my level best to help you.
Ok then. I’m glad that I was able to work with you. I will do my level best to make you feel better.
Thank you for your cooperation, have a good day. Bye for now, take care.

In case Time Falls Short:
“Oh! Mr. Smith, I have called away and I have to leave now. It is good that you came in. I will come back to you as soon as I get free” leave with a SMILE.

You did not finish Questions or PE and only a few minutes are left
Proceed to wrapping up
“ I have got an emergency call on my pager and I need to leave within a few minutes. I will get back to you as soon as I return back. However, before leaving I would like to summarize my findings so far….” Then start counseling.

Points to remember in CIS:
Do not ask leading question
Do not avoid eye contact except when paraphrasing and writing notes
Be nonjudgmental (avoid words like good very good! Excellent. Instead Say ok , Thank you)
Always use lay language. Don’t use CT, MRI, EKG
DO not interrupt the patient while he is speaking. Facilitate by saying Uhuh…uhuh go ahead! Tell me more,
Never alarm the patient

Points to remember when answering a challenging question
first say that you understand his concern
then answer the question appropriately
then reassure
For e.g.: Doc! Am I going to get better? I understand your concern Mr. Steve. Your recovery basically depends on your response to our treatment and your underlying condition causing these symptoms. We will do our best to help you irrespective of final diagnosis and outcome of the treatment. OR

SP: “Do you think I have cancer, doctor?”
Dr: “Well. I understand your concern, Mr.___. I cannot exclude the possibility of cancer at this point. We need to do additional testing. Regardless of the final diagnosis, however, I want you to be assured that I will do everything in my account to help you and I will be available for any support you need.”

Challenging Situations:
SP in pain and asking for pain medication – “Mr. … I will get you something to help with your pain. First, I need to ask you some questions and run a few tests to get a better idea of what is causing your pain before we mask your symptom`s. I will be as quick and gentle as possible.”

Crying , SP is stress, distress, concern or worried– Pause silence for several seconds. Offer the tissue box. Hold his / her shoulder gently for couple of seconds. “That must have been very difficult for you. Any one dealing with problem would feel angry (sad, upset, etc…) Can you tell me about it?” “How do you feel about it? How it has changed your life?”

Light sensitivity – offer to pull down the shades or dim lights

Uncooperative patient for physical examination
 First do as much of the exam as you can with the patient in his or her preferred position.
 Then for remaining exam – explain how important it is to do the exam correctly and ask him to move.
 Acknowledge the patient’s feeling and / or frustration.
 Reassure him that you are there to give him your undivided attention and will do everything possible to help him feel better.
 Let’s now begin discussing more about your discomfort.
 Offer him help to move.
 If the patient still refuses, simply move on and document in your note.

Angry patient –
 Stay calm. Don’t be scared. Let him express his feelings.
 Ask about the reason for his anger.
 “Mr. I can see you are angry. Can I help?”
 “I know you are depressed about your symptoms and I want to help you feel better.” “Here is a box of tissues. Are you able to tell me why you are crying?”

Don’t want international doctor:
 “I understand your concern. But let me inform you that I am a US-licensed physician, fully qualified to manage your care, and I can assure you that I am here to help you today. If you still feel this way at the end of our meeting, I will make a note so that you can see someone else next time. Let us get started.”

Verbose patient. Redirect him. At the right moment, gently interrupt and guide the patient back to discussion of symptoms. USE CLOSE ENDED QUESTIONS TO DO SO.
Dr: “I understand that _____ is important to you, but I want to get back to your problem. Can you tell me more about ___________, please? Thank you

Anxious patient – Encourage the patient to talk
Pain – Patient visibly in pain – Dr: “Mr. .. is there anything I can do to make you more comfortable?”
Poor vision & hearing- tell her where you are sitting and help her with anything she needs or maneuvers she may need to perform. Sit close to him and speak into best ear if one is better. Face the patient directly to allow him to read lips.
I don’t have time. Just give me antibiotics.
 Explain that routine procedures are necessary. Be as specific as possible:
 “Antibiotics treat infections and are not always indicated for the type of symptoms you have. I will need a few minutes to ask you a few questions and perform a brief examination to make sure we get you the correct treatment. After this examination, we can discuss whether or not antibiotics will help you to feel better.”
Domestic abuse:
Have you been emotionally or physically hurt or abused by anybody?
“SAFE GUARD”
 Safety- Are you concerned for your / your kids safety?.
 Afraid - Are you afraid of? For what?
 Friends / Family Do you have support of your friends and family?
 Emergency plan – Do you have any emergency plan to implement if situation arises?
 Is there Guns at home
 Alcohol
 Relationship with household adult members/father’s reaction toward the kids
 Depression/Domestic violence

Depressed non responding patient – I know this is very tough time in your life, but I assure you that we can deal with this much better together. I really want to understand your problem and help you as a friend and a physician. You said you were perfectly happy and normal before months ago – could you try and tell me what exactly happened months ago that started this?
I want to die doctor – I know this is very tough time in your life, but I also know that running away from problems is not the answer. I really want to understand your problem and help you get your strength back, because I know it is possible. We can deal with this together.
Don’t have money – Not having enough money doesn’t mean you can’t get treatment. We will refer you to a social worker who can help you find resources.
Pt doesn’t know the names of his medication or is taking medications whose names you don’t recognize. – Ask the patient if he has a prescription or a written list of medication he is currently taking.

Challenging Questions:
SP “Doctor, do you think I will be able to move my arm again like before?
Dr: “I hope so, but first we need to confirm whether it’s broken or dislocated and whether there is any nerve or muscle damage.”

SP: “My father had colon cancer. Could I have it too?”
Dr: “It is a possibility. Tell me more about the symptoms you’re having that concern you with regard to cancer.” OR “Mr……..I understand how scary this can be, but I need to be very systematic and careful. So let us take one step at a time. First I need to have you take some blood and urine tests & some x-rays. Then after I study the result with your examination findings, I will be able to give you a definitive diagnosis and explain your options for treatment. You and I will sit down at that time & go over everything in detail, okay?”

SP: “Do you think that I did the right thing by coming here and telling you about my child’s fever?” “Is my child going to be okay?”
Dr: “You absolutely did the right thing. Maria may have an infection that needs antibiotics; we need to examine her here in the office and then decide whether she needs any more testing or treatment.”

SP: “Do I need antibiotics to get better?”
Dr: “Maybe. Antibiotics don’t help in bronchitis, but they will help if we find pneumonia

SP: “Will I get better if I stop smoking?”
Dr: “Well, we still have to sort out exactly what’s making you sick. Stopping smoking should help your chronic cough, and over the long term it will significantly decrease your cancer risk.”

SP: “My father had pancreatic cancer. Could I have it too?”
Dr: “It’s highly unlikely; your symptoms are very unusual for pancreatic cancer. Regardless, some routine blood and x-ray tests should help us exclude that as a possibility.”

SP: “Doctor, do you think I will benefit from this medication?
Dr: ”I need to review your history to better understand your need to this medication

SP: Doctor, am I going to die? – Balance your answer so they neither alarm the patient nor give false reassurance.
Dr.: “Your condition may be serious, but until I get more of the tests back, I can’t really tell you more than that. You should also know that we have an excellent team of doctors & nurses to help you through this”. OR
“I understand your concern. There is no need to be unnecessarily concerned at this time. The most important thing is that you are here now and we will do everything we can to help you”.

SP: “What kind of test is this? Will it hurt me?” - Explain before asked if possible.
Dr: “It might hurt for just a moment or two. I’ll warn you right before it might hurt. Please bear with me; this will assist me in discovering what is wrong and how I can best help you”.

SP`: Is this cancer !!!!!!!!
Dr: Mrs. Hicks, I understand your apprehension, but we need to wait for investigations.
I will keep you informed

SP: Doctor, do you think I have a fracture??
Dr: “It is a possibility, but we must wait for your X-ray to arrive”
SP: I am in pain ! Please give me a pain killer!
Dr: I know it is not easy to bear the pain, but without unless we know what we are dealing with; it will be tough to decide the right pain-killer. As soon as we are done with a quick examination, I will have my nurse treat your pain. Is that fine Mr. Harrison?

PATIENTS NOTES

Level of consciousness: Alert, lethargic, stuporous
Affect:
 Full Range
 Blunted: patient does not display emotion; answers in a monotone may speak slowly, etc.
 Labile: changes in a rapid, abrupt, excessive way
 Persistent: persists unduly long-laugh too long
 Mood: describe depression, dysphoric, euthymic, hypomanic
 Anxiety: a feeling of fearful anticipation which is not attributable to real danger and occurs either in attacks or as a persistent state. I t can have physical symptoms such as manifestations of autonomic over activity )palpitation, dry mouth, swearing, trembling, etc. )
 Apathy: total loss of emotion

HITSORY PEARLS
1 - Ask about thyroid symptoms in: weight changes, depression, amenorrhea

2 - Abdominal pain: ask about black or tarry stools

3 - Abuse: ask about emergency plan, if family and/or friends know about what's going on

4 - Bruise, depression: ask about abuse

5 - Chronic cough: ask about HIV, TB, ACE inhibitors use

6 - CNS case: ask about previous stroke, migraine, seizures, syphilis

7 - Dizziness: ask about tendency to fall towards left or right

8 - Depression: ask about guns and pills at home, auditory hallucinations

9 - DM: ask about vision, sensation, ED, counsel about foot care

10 - Forgetfulness: ask about ADLs, IADLs, social support, head trauma, depression, syphilis

11 - Jaundice: ask about urine and stools color

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!"

14 - Insomnia: ask if the problem is falling asleep, staying asleep or waking from sleep; frequent movements of legs, hot flushes; order sleep diary for 2 weeks

15 - Menopause: ask about mood swings, family breast and uterine cancer history; counsel about weight bearing exercises (osteoporosis prevention)

16 - Palpitations, insomnia: ask about caffeine intake

17 - Ob/gyn case: ask details about periods, cycles, intercourse, pap smear

18 - Rash: ask about sun exposure, ticks, mosquitoes bites

19 - Pain in hand: ask about repetitive movements, such as operating a key board

20 - Obesity: ask about joint pain, hypercholesterolemia

21 - SOB: ask about wheezing, orthopnea, 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

25 - Trauma in elderly: ask about abuse

26 - Vomiting: ask about fever, headache, if it is projectile; if yes for any, do a fundoscopy

ADLs: activities of daily living = DEATH = Dressing, Eating, Ambulating, Toileting, Hygiene
IADLs: instrumental activities of daily living = SHAFT = Shopping, Housekeeping, Accounting, Food preparation, Transportation

PE pearls

1 - Any bleeding: order orthostatics

2 - DM: fundoscopy, test sensation and vibration, pulses, auscultate carotids, examine feet

3 - Dizziness: order orthostatics

4 - COPD: check sinus, do a complete cardiologic exam

5 - Confusion, forgetfulness: auscultate carotids, MMSE, fundoscopy

6 - Insomnia: check thyroid, DTRs

7 - Low back pain: straight leg raising test, lumbosacral range of motion, gait, order rectal exam including "saddle area" sensory exam, DTRs in legs

8 - Palpitations: check thyroid, extremities tremor, DTRs

Picky eater telephone case

History taking:

1. Good Morning, Mrs. Smith. This is Dr. XYZ. I am an attending physician here at the medical center. How can I help you today? (My son is a picky eater; I am wonder if you could give me some advice on what I should do about it?).
2. Ok, Mrs. Smith, I’d like to get a few details from you about your son. How old is your son? ( He is 4 years old)
3. How long has he been a picky eater? ( since six months ago)
4. Could you please tell me what is the reason that you think you son is a picky eater? (OK, for example, he only eats some potato chips, candies and drinks fruit He doesn’t like to eat regular meal . )
5. Is his picky eating habit getting worse or getter better ( getter worse)
6. Has he ever eaten well when he got really hungry? ( Yes, he ate a lot when he came back from playground)
7. Does he watch TV before dinner? ( yes, he watches TV sometimes)
8. Does he have any pain in his belly? ( No, he didn’t mention it)
9. Does he have any problems with his bowel movement? ( He has constipation )
10. How many times a week does he have bowel movements? ( 3-4 times a week)
( Now ask about associated symptom)
11. Does he have any headaches? a fever? Cough? Short of breath? Diarrhea?(No)
( Now ask about PAM HUGS FOSS question)
12. Did he ever have similar episodes in the past? (No)
13. Was he ever diagnosed with any medical illness before? ( No)
14. Does he have any allergies? ( No)
15. Is he taking any medications ?(No)
16. Has he ever been hospitalized? ( No)
17. Does he have any problems with his urination? (No)
18. Does he have any problem with sleeping?
19. Does anyone in your family also have the same problem? (Yes, I was a pick eater when I was a child)
20. How many children do you have? ( he is the only one)
21. How much time do parents spend time with him? ( a few hours a day, because both of us work)
22. Who takes care of your child when you are working? ( he goes to day care center)
23. What kind of house do you live? ( very old one)
Then ask Milestones questions ( I use IDIOT mnemonic)
24. Are his immunizations up to date? (yes)
25. When was his last well-child check-up? ( six months ago, everything is fine at that time?)
26. Did he have any infections before? (No)
27. Did you have any problems with your delivery? ( No, everything was fine)
28. Has your family moved recently? ( Yes, we just moved here six months ago)

Well, Mrs. Smith, thank you very much for answering my question. Do you have anything that you would like to tell me about? (No)

Ok, I would like to give you my impression right now. First let me summarize what you have just told me. You said your 4-year-old son has been a picky eater that started 6 months ago. He likes to eat some potato chips and drinks fruit juice but not regular meal. He also likes to watch TV before dinner. He also has constipation for past six months. Is that right? (Yes)

Mrs. Smith, based on the information you told me, I think your son may be experiencing a habitual eating disorder, however, we also need to exclude some other possibilities , such as lead-poisoning or iron-deficiency anemia. For that reason, I would like to examine him personally and order some tests on him before I make any diagnosis or give any advices. Is it convenient for you to bring him to here? (I am sorry; I cannot bring him to the hospital. Would you please just give me some advices over the telephones?)

Mrs. Smith, is there a reason why you cannot bring your son to here? (Actually, my husband is out of town and I have no means of transportation.)

OK, Mrs. 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)

Alright then, I will see you once you get to the hospital. Take care.

D/D:
1. Habitual eating disorder
2. Lead poisoning
3. Iron-deficiency anemia
4. Fiber-lack diet
5. Parasitic Infections

Work-ups:
1. CBC and electrolytes
2. Serum lead level
3. Stool for OVA and parasites
4. USG Abdomen