+ L I Q R (If Pain) Doorway Information Location: Would you please show me the exact location of your pain ?

Intensity: On a scale of 1 to 10, how severe is your pain? (with 10 being the most severe pain of your life) Quality: How will you describe your pain? burning, Cramping, dull or sharp, pressure like, pulsating, Piercing? Radiation: Does the pain travel anywhere else? ------------------------------------+A B C O (If Vomiting, diarrhea, constipation, cough, vaginal discharge) Amount: Can you estimate the amount of xxxxx( blood, phlegm, discharge, vomitus)? a teaspoon, a table spoon, or a cupful? How many times per day did you have diarrhea? Was it watery, fatty or bloody? Blood: Have you noticed any blood in it? Color: What color was vomitus/discharge/stool? Odor: How did it smell any specific odor? ------------------------------------A A A ( for all cases) A Alleviating factors: Does anything make it better? A Aggravating factors: Does anything make it worse? Progression: How did it progress? Did it get better or did it become worse? Constant v/s intermittent: Is it constant or does it come and go? (If intermittent: Frequency: How often does it happen? How many episodes/times per day do you have it? Duration: How long does it last each time?) A Associated problem:Do you have any other associated problem like Nausea,Fever,headache,Neck stiffness,Limb weakness,Numbness or tingling, .

Write Name, VS, CC, DDx & mnemonics

Knock the Door 3 times, wait 3sec, Go!!! Its Showtime!!

Introduce Yourself:

Doc: Mr. Smith? SP: Yes Doc: "Hi, I am Dr. ., the physician on duty today. Its nice to meet you (Handshake) Doc: "Is everything ok in the room? SP: Yes Ok now just let me make you more comfortable" (Drape Pt.) Doc: "I hope you don't mind if I sit and take some notes as you speak" Doc: So Mr. Smith, how can I help you today? SP: . Oh I am sorry to hear that, I will do best to help you

HISTORY OF PRESENT ILLNESS (HPI)

Chief Complaint (cc) Use your mnemonics.

HPI ( History of Present Illness): O P P C (LIQR-ABCO)AAA

Onset: When did it start first? Was the onset sudden or gradual? How long have you been feeling this way? ( I feel a bit down) Precipitating factor: What were you doing when it started? Do you remember anything which could be responsible for it?

PAST MEDICAL HISTORY Before PMH

Now I am going to ask you some questions about your past medical Hx PAM HUGS WAT FOSS P (PMH) (Dj Vu) Doc Have you ever had similar problem before? Was it diagnosed? Was it treated? Doc: Do you have any other medical conditions?, like High blood pressure, Diabetes, high Cholesterol?... 1

A (Allergies) Doc: Are you allergic to anything, food or medicine? M (Medication) Doc: Are you taking any medications? Prescribed or over the counter? HITS (Hospitalizations, Injuries, trauma, Surgeries) Doc: Have you ever been hospitalized? Any surgeries in the past? Any injuries or accidents? Have you ever received transfusions? U (Urination) Doc: Have you noticed any changes in your Urinary Habits? G (Gastrointestinal) Doc: What about in your Bowel Movements? S (Sleep) Doc: Are you sleeping ok? W Weight: Have you had any significant change in your weight recently? A Apetite: Have you had any change in your appetite? T Travel: Did you have any recent travel

Doc: Are you sexually active? Doc: In the last year how many sexual partners have you had? Are they male, female, or both? Doc: Have you noticed any changes in your sexual function? Doc: Do you always use condoms? Have you ever had any STD Sexual transmitted disease? Did you get any treatment? And your sexual partner? Before Social History Doc: Now let me ask you some qs about your lifestyle S (Social history) L SODA WET L Who do you Live with? S Do you smoke? How many packs a day? For how many years? O Do you drink Alcohol? What do you drink? How many glasses, beers a day, how many days a week? D Do you use any recreational drugs? What do you use? When was the last time you had it? A How is your appetite? How is your diet? Any recent weight changes? How many pounds? Over what period of time? W What kind of work do you do? Is it stressful? E How often do you exercise? T Have you recently traveled?

Before Family Hx
Now I am going to ask you some qs about your Familys health F (Family Hx) Doc: Does anybody in your family have the same problem? Are there any medical conditions that run in your family? like Diabetes, High blood pressure, Cancer? Are your parents healthy? Before Obstetric Hx Now I am going to ask you some qs about your Obstetric Hx Ok? O (Obstetric Hx) Doc: When did you have your first menstrual period? When was your last menstrual period LMP? Was it regular? Doc: How many times have you being pregnant? Any abnormalities or complications? Any miscarriages? At how many weeks? Doc: How many children do you have? Are they healthy? Doc: What are you using for birth control?

Finishing Qs & Before Physical Exam All right Mr. Lee thanks for answering all these questions. Now Ill need to do your physical exam, so Ill just wash my hands first. Ok Mr./ Ms. According what you said/ So as you said . Is there anything else youd like to tell me ?

Wash hands

Before Sexual History Ok Mr. Smith, now I am going to ask you some very personal qs, but let me re-assure you that everything we talk will be kept confidential ok? S (Sexual history)

Doc: Ok Mr. Smith, now let me begin by HEENT - HEAD Inspection:

2

Doc: Ok Mr. Smith, now I am going to start by examining your head, let me look at your head first Palpation: Doc: Now I am going to press on some areas on your face, to examine your sinuses, please let me know if you feel any pain. Conjunctiva: Doc: Let me check your eyes, can you look up for me please? TMJ: Doc: Please bite really hard? Cranial Bones: Doc: Now I am going to press on some areas of your skull, if you have any pain just let me know please? Lymph nodes: NECK

3) Pupillary Response to Light and Convergence Doc: Mr. Smith, please look ahead, I am going to shine this penlight on your eyes?, Continue to look ahead, as I shine this light from the side
1st: Look for the Direct Pupillary Reflex 2nd: Look for the Consensual Pupillary Reflex

4) EOM Function: Cardinal Position of Gaze:

Doc: Mrs. Clark, Id like you to follow my finger with your eyes only, please do not move your head, follow it out here, here, Now, I want you to watch my finger carefully as I go very close (Convergence Test) 5) Fundoscopy: Ophthalmoscope
Remove yours and the patients glasses, prove the light.

Doc: Now I am going to check if you have any swollen glands, please let me know if you have any discomfort Supraclavicular: Please take a deep breath in, in, in..out

Law Of The Right Right / Left - Left: Doc: Mr. Clark could you look to a fixed point on the wall please, I am going to check inside your eyes?, thanks. EARS

Thyroid Gland Doc: I am going to examine the gland in front of your neck for that I need you to swallow when I ask you, do you need a glass of water? Please swallow? Ok, thanks EYES: 1) Pocket Snellen Chart

1) Othoscope Doc: Now I am going to check your ears, let me pull your ear first, do you feel any pain, now let me check inside, now the other. 2) Tuning Fork Test: Rinne and Weber Test Doc: Now I am going to strike this tuning fork on my hand and place it on the back of your ear. Doc: Can you hear this? Can you hear better now? Rinne Test
Usually: AC > BC

Doc: Mr. Smith, could you please cover one eye and read the smallest line possible? now with the other eye? 2) Visual Fields: Remove glasses (yours and
pts), 2 feet std

Doc: Could you please cover your right eye, and with your left eye look at my nose only, when you see my finger moving, please say yes Doc: Can you see this, what about here? SP: Yes/No

Weber Test

Doc: Now I am going to place it on the top of your head. Do you feel anything? SP:
Yes, vibration

Doc: s it the same in both sides? SP: Yes

Patient (L) Doc(R)

NOSE
3

Doc: Mr. X, could you please extend your neck? I am going to lift the tip of your nose to check inside THROAT - MOUTH Doc: Mr. X. could you open your mouth for me please? Stick out your tongue, move it side to side (XII Cranial) Now I am going to place this tongue depressor, say Ah (IX and X) you can put your tongue back, thanks.

Tactile Fremitus: Doc: Could you cross your arms in front? Please say 99 every time I place my hands? 99?, again, again

Cranial Nerves: I II, III, IV, VI done H VIII. - Vestibulocochlear (auditory) done IX & X. - Say Ah done XII. Done V.
Mandible S & M

Percussion Auscultation Percussion: Doc: I am going to tap on your back Auscultation: Warm the Stethoscope Doc: I am going to listen to your lungs, please open your mouth and take a deep breath, in and out through your mouth, again, again Ok, now breath normally, Thanks. HEART Palpation: Doc: Now please lean forward, let me check your heart First, I am going to press on some areas on your chest to feel your heart impulse

Trigeminal

Opht

&

Maxil

Sensory Function: forehead, cheeks and jaw Doc: Mr. X, Im going to take this gauze pad and touch some places on your face with it, please close your eyes Did you feel this did it feel similar or not?

Aortic Area: 2 ICS (Left), Pulmonary Area: 2 ICS (Right) Tricuspid Area: 3 ICS (LLSB) Mitral area: 5 ICS & Midclavicular Left Line

VII. Facial Doc: Smile for me please? Big Smile Doc: Could you frown for me? XI. Spinal Accessory Grab Pts shoulders Doc: Could you push up your shoulders against my resistance? Auscultation: On 4 cardiac areas Doc: Please lean forward ABDOMEN
Inspection:

LUNGS

Doc: Please let me untie your gown so I can examine your lungs Palpation: Chest Excursion Doc: Now I am going to hold your back, please take a deep breath, again, again, ok thanks

Doc: Mr. X, let me uncover your belly to examine it Could you please turn your head to the other side & cough for me? Auscultation: Now please, let me listen to your belly . Liver

Percussion: Now I need to tap on ur tummy. Palpation: Look at the pts face expression. Light palpation: One hand. I need to press lightly on ur stomach area. 4

Doc: Any tenderness here?(6 points) Check the reno ureteral points for pain.
Deep Palpation: 2 hands, rolling motion. I need to press a little more deeply now.

Radial & Femoral Pulses: (if thinking on Coarctation of Ao) Popliteal Pulses: place thumbs on the patella.

Doc: Any tenderness (pain) here? Here? Doc: I know it feels a little uncomfortable, but if you feel pain please let me know
Special palpation: Liver, Spleen. Liver Palpation

Post Tibial malleolus

Pulses:

press

fingers

against

Dorsalis Pedia Pulses:

Doc: Take a deep breath in out Spleen

Left to the navel.

Neurological Exam

Special Tests

Mental Status - Cranial Nerves - Sensory function Motor function - Reflexes Cerebellar function

Murphys Sign Cholecystitis

Doc: I am going to press on the right side below your ribs to feel your liver, please take a deep breath in, in out. Thanks. Any pain? SP: yes (+)
Murphy Appendicitis Mc Burney

Mental Status Quick Minimental Doc: Mrs. Smith, I am going to ask you few questions to asses your attention and memory ok? Orientation: Can you please tell me your full name? What is the date today? Can you tell me what city are we in? Where are you now? Memory: Mrs. Smith please say these words: boat, table & pencil. (Immediate recall). I am going to ask you to recall these words later ok. Attention & Concentration: Now spell the word "WORLD" backwards for me please? Language Test Can you close your eyes put your hands together and bring them on to your belly and then on to your back? * Mrs. Smith I want you to recall the 3 words that I told you few minutes ago. (Delayed Recall) Spatial Ability: Can you copy the following drawing? Sensory Function: Position Sense: Proprioception Doc: Mr. X, could you close your eyes and tell me where did I just touch you?.. Hand, foot, Doc: Did that feel similar?
Hold the finger 5

Doc: Now I am going to press on the left lower side of your belly, please take a deep breath and let me know if it hurts?
Rovsing's Sign.- (contra lateral pain)

Doc: I am going to press on this side, where do you feel the pain, ?
Rebound Tenderness.- pain when removing the pressure (Peritonitis)

Doc: Now I need to press in on your stomach area. Tell me if it hurts more when I press in or let go.
Psoas sign.right thigh

Pain on passive extension of the

Doc: Mr. X, please lay on your left side, I need to lift your leg and pull it back . Do you feel any pain?
Psoas Obturator Obturator sign. Passive internal rotation of the flexed thigh

Doc: Mr. X, I am going to move your leg to the side while I press on the side of your knee, do you feel any pain? CVA tenderness: I m going to tap on your backnow. Let me know if it hurts?

Extremities
Radial & Brachial

Doc: This is up and this is down Doc: Tell me, what is this? SP. Vibration: Use the Tuning fork Doc: Close your eyes please? Do you feel anything? What do you feel?
Vibration

Doc: Walk towards me; now, on your toes, now on your heels thanks. Walk, one foot in front of the other in a straight line

Doc: What about now? Doc: Stronger now? Weaker? Or the same? toes. Sharp and Dullness: Doc: Close your eyes, this is dull and this is sharp Doc: What is this? Sharp or dull?
Upp & Low limbs

Reflexes DTR Biceps Patella

(Knee)

Achilles

Motor function
Upper Limbs

Doc: Grip my hand, dont let me go relax Doc: Make a fist. Dont let me open, relax Doc: bring your arms in front, palms up like this, dont let me push you down, now palms down, dont let me push up ok relax
Lower Limbs

Doc: Push your legs forward against my resistance, now backwardsrelax now Cerebellar function Finger to Nose Test Doc: I am going here, please touch touch your nose, while I move my positions Romberg test to place my finger my finger and then now do the same finger in different

Doc: Please stand still with feet together and open your arms aside . Close your eyes and balance yourself. Dont worry I will be behind you in case you need some assistance. Examination of Gait

Obstetric and Gyn History: Ok Mrs. Smith now I would like to ask few questions regarding your gynecological health, Is that ok with you?, continue as follows: If it is not a Obstetrical/Gynecological case just ask : 1. When was your last menstrual period?. 2. Are/Were your cycles regular?. If it is a OB/Gyn case enquire about SPECIFIC HISTORY QUESTIONS LMP RTV CS PAP LMP !! "When was your last menstrual period? Menarche "How old were you when you had your first period?" Period ( lasts .... days?) "How many days does your period last?" Reglarity ( every .... wks?) "Are your periods regular?" Tampoons/Pads # per day "How many pads do you use in a heavy day?" Vaginal discharge, itching , dryness "Have you ever had any vaginal discharge?" If YES, then ask What is the color of the discharge? Does it have any bad odor? Do you have any vaginal itching?" "Have you had any sores or infections around the vagina?" Cramps (Dysmenorrhea) "Do you have abdominal cramps/pain with your periods?" Have you ever had any pain in your belly? If YES continue with all the questions given under pain in present history Do you have any problems controlling your bladder? 6

Spotting ( intermenstrual / post coital ) "Have you ever bleed between cycles?" "Did you ever notice any bleeding after intercourse?" Pregnency ( Hx & complications) Have you ever been pregnant?. "How many times?", "How were the births?"" Have you had any complications during delivery?". Abortion /miscarriage "Any miscarriages or abortions?". If YES How many times did you abort? In which month/week of your pregnancy? Do you know the reason (s) for the abortion? "Have you had any other problems or complications with the pregnancies?". PAP smear ( last time result ?, Hx of past abnormal result ?/ "Have you been getting regular pap smears?", "When did you have the last Pap smear?".

Urinary complaints:
If the case is not related to urinary system just ask: Have you had any problems with your urination ? If related to Genitourinary system the take a detailed history. Have you noticed any change in the color of your urine? Is it constantly the same color through out the day?

FINISHED PUBS
Frequency ( How frequent do u Ux) Incontinence( Do u hav trouble holding Ux) Nocturia ( do u hav 2 wak up @ Night) Incomplete emptying ( do u feel fullnes after Ux) Stream (How is ur stream?) Hematuria ( did u notic any blood) Hesitancy (do u hav 2 wait b4 starting Ux) Dysuria (Did u hav diff Ux) Pyuria ( did u pus in Ux) Urgency (do u hav 2 rush) Burning (dysuria) (does it burn) Strain (Do u hav to strain during Ux)