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1
FOR THE IMGs
_____________________________________________________________________
USMLE STEP 2 CS
_____________________...
2
Preface
The USMLE STEP 2 CS is a source of anxiety and concerns among all IMG’s and
that what inspired me to write this ...
3
CONTENTS
The exam …………………………………………………………………………….4
Study tips ………………………………………………………………………….….5
Chapter 1
History …….……………...
4
The Exam
The exam is in the form of 11 or 12 cases in which you are requested to take history
and do physical exam on ea...
5
STUDY TIPS
1- Practicing the cases is the most important single strategy to pass the exam. The
time constraints during t...
6
CHAPTER ONE
HISTORY
7
SAMPLE of how you should divide your history and physical exam paper
Example 1
MR ADAM
55 yo
Vs WNL
Mental check list
1-...
8
Example 2
MR ADAM Mental check list:
50 yo 1-
Vs WNL 2-
3-
HPI + ROS
L I Q O R A A P A
P A M H S F O S S
Positives in ph...
9
History taking
Is divided into 3 main parts:
1- HPI (history of present illness) + ROS (review of systems) + History to ...
10
8- SEIZURES ABCD, Aura (signs that the attack will happen),
Bowel/bladder control, Bite tongue, Consciousness lost, Con...
11
19- HEARING LOSS Ear symptoms, exposure to loud noises, insertion of
foreign bodies, neurological problems (weakness, n...
12
34- BURNING URINATION IN YOUNG FEMALE OCD-F-AAPA, CD-PPP
(for vulvovaginitis, PID).
35- DRUG REFILL OR FOLLOW UP HTN DM...
13
2-Schematic drawing for associated symptoms to ask specific to the system of the CC:
ABDOMEN
RESPIRATORY AND CARDIAC
14
NEUROLOGICAL
OB/GYN (CD-PPP)
15
ROS
History to think about
These are important points in different cases that are commonly missed, you will
not necessa...
16
PAM-HS-FOSS
P Past history similar problems.
Past history of medical problems.
A Allergies.
M Medications (prescription...
17
Psychiatric history
Is divided into: 1- HPI = TT-DSM-FAWR + ROS
2- PAM-HS-FOSS
Think what do you think your problem is ...
18
CHAPTER TWO
PHYSCIAL EXAMINATION
19
Physical exam
The examination room is equipped with all the instruments that you are suspected to
use during the physic...
20
Extremities Pulsations (radial and dorsalis pedis)
LL edema.
Skin.
Systems examination
Chest examination: (patient sitt...
21
Abdominal examination: (lying down)
1. Inspection: Swelling Scar Pulsations Peristalsis.
2. Auscultation: Bowl Bruit
3....
22
Neurological examination:
1- Mental status : can be done at end of the history, beginning of physical or end of
physica...
23
4- Sensory: “I would like to check sensory perception in different areas of your body,
ok?”
a. Light touch(cotton), Pai...
24
MISCELANEOUS EXAMINTAION
A- EYE EXAMINATION:
1. Conjunctiva : “please look upwards” while you are pulling the lower
lid...
25
B- MUSCULOSKELETAL EXAMINATION:
1- Inspect and compare (don’t forget the back of the areal you examine)
Appearance Atro...
26
B- EAR EXAMINATION:
1. Inspect and palpate + mastoid “please tell me if you feel pain”
2. Hearing :
 Whisper “please c...
27
F- EXAMINATION IN SPECIAL SITUATIONS:
 If PE in DD (SOB and/or Cough) calf tenderness.
 Difficulty swallowing give th...
28
CHAPTER THREE
PATIENT NOTES
29
PATIENT NOTES
sample of the exam paper
Patient notes are written from the bottom to the top starting with the different...
30
WRITING THE PATIENT NOTES
HISTORY:
 General format of the HPI:
… Yo F/M c/o …., LIQOR-F-AAPA or OCD-F-AAPA, patient
re...
31
PHYSICAL EXAMINATION:
Normal in physical examination:
VS (vital signs): WNL
HEENT (head,eye,ear,nose,throat) :
 Normoc...
32
OB/GYN:
 G…P..., LMP…, regular/irregular, painful or not, bleeding or not (postcoital
and/or intermenstrual), discharg...
33
DIFFERENTIAL DIAGNOSIS:
 Maximum of 5.
 Written in descending order of likelihood.
 Thyroid problems and drug induce...
34
CHAPTER FOUR
DIFFERENTIAL DIAGNOSIS OF IMPORTANT PRESENTATIONS
35
DD OF IMPORTANT PRSENTATIONS:
(The aim of this list is to help you make a DD in your mind before the encounter; it is
n...
36
SORE THROAT:
1. Bacterial pharyngitis (streptococcus pneumonia, gonococcal, mycoplasma)
2. Viral pharyngitis
3. Posteri...
37
CONSTIPATION:
1. Functional
2. Obstructive: cancer, intestinal obstruction
3. Metabolic: hypercalcemia, hypothyroidism,...
38
DIFFICUTY WITH URINATION:
1. BPH
2. Prostatic carcinoma
3. Urolithiasis
4. UTI
5. Urethral stricture
6. Bladder cancer
...
39
BACK PAIN:
1. Lumber disc prolapse
2. Lumber muscle strain
3. Lumbar spinal stenosis
4. Osteoporosis
5. Degenerative ar...
40
MULTIPLE BRUISES:
1. Accident
2. Domestic violence
3. Bleeding disorder
4. Autoimmune collagen vascular disease
IMPOTEN...
41
HEADACHE:
1. Primary:
Migraine, cluster headache, tension headache
2. Secondary:
Extra cranial
Glaucoma, errors of refr...
42
HEARING LOSS:
Conductive
FB, cerumen impaction, TM perforation, post OM effusion, otosclerosis,
cholesteatoma
Sensorine...
43
CHILD WITH FEVER:
1. Respiratory tract infection
2. OM
3. Exanthematous disease
4. Meningitis
5. Encephalitis
6. UTI
7....
44
CHAPTER FIVE
CLOSURE AND COUNCELLING
45
ENRANCE, CLOSURE AND COUNSELLING
ENTRANCE?
 Knock and enter
 You: “Hallo Mr/Mrs …… I am dr ….. I am ……, are the room ...
46
COUNSELLING IN SPECIAL SITUATIONS:
COUNSELING IN DOMESTIC VIOLENCE: (spousal, child or geriatric abuse)
 Mr/Mrs ……. I ...
47
 You: “ok Mr/Mrs ….., I understand you are not ready now to quit
smoking/alcohol drinking, when you decide to quit I w...
48
COUNSELLING IN DIAGNOSED OR HIGH RISK HIV CASES:
 Safe sexual practice (use of condoms regularly, inform partner, avoi...
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Gold Standard for the USMLE Step 2 CS - GOLD STANDARD FOR THE

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Gold Standard for the USMLE Step 2 CS - GOLD STANDARD FOR THE

  1. 1. 1 FOR THE IMGs _____________________________________________________________________ USMLE STEP 2 CS _____________________________________________________________________  A GUIDE THAT CONTAINS ALL THAT YOU NEED TO PASS THE CS EXAM.  GENERAL HISTORY TAKING AND PHYSICAL EXAMINATION THAT CAN BE APPLIED TO ALMOST ALL CASES SPARING LONG HOURS OF STUDYING EACH CASE ALONE.  HOW TO PERFORM A COMPLETE AND RAPID CLOSURE AND COUNCELING.  USEFULL STUDY TIPS FROM STUDENTS WHO PASSED THE EXAM.  USEFULL EXAM EXPERIENCE FROM EXAM PASSERS.  USEFULL STRATEGIES FOR CHALLENGING PATIENTS WHATEVER THE CHALLENGING QUESTIONS ARE.  WHAT TO SAY AND WHAT NOT TO SAY DURING THE ENCOUNTER.  REVIEW REPORTS ABOUT THE AVAILABLE CS BOOKS AND VIDEOS.  CD INCLUDED CONTAINING PHYSICAL EXAMINATION VIDEOS. FIRST EDITION GOLD STANDARD
  2. 2. 2 Preface The USMLE STEP 2 CS is a source of anxiety and concerns among all IMG’s and that what inspired me to write this book. Being a USMLE step 1 and 2 passer with scores of 99 , I felt while studying the CS that I could make It a lot easier for a lot of fellow IMG’s who are not used to taking history and doing physical examination both in English and by the American school of practice. Through the help of a lot of fellow residents, attendings and friends I present to you this book that will make a process that may be painful and difficult feel a lot better and easier. This GOLD STANDARD includes:  A GUIDE THAT CONTAINS ALL THAT YOU NEED TO PASS THE CS EXAM.  GENERAL HISTORY TAKINGAND PHYSICAL EXAMINATION THAT CAN BE APPLIED TO ALMOST ALL CASES SPARINGLONGHOURS OF STUDYINGEACH CASE ALONE.  EVEN IF YOU DONT KNOW THE CASE FOLLOW THESE STEPS AND YOU WILL PASS.  USEFULL STUDY TIPS FROM STUDENTS WHO PASSED THE EXAM.  USEFULL EXAM EXPERIENCE FROM EXAM PASSERS.  USEFULL STRATEGIES FOR CHALLENGINGPATIENTS WHATEVER THE CHALLENGINGQUESTIONS ARE.  WHAT TO SAY AND WHAT NOT TO SAY DURINGTHE ENCOUNTER.  HOW TO PERFORM A COMPLETE AND RAPID CLOSURE.  USEFUL WEBSITES AND BOOKS FOR THE EXAM. Aly H. Abayazeed
  3. 3. 3 CONTENTS The exam …………………………………………………………………………….4 Study tips ………………………………………………………………………….….5 Chapter 1 History …….…………………………………………………………………………6 Chapter 2 Physical examination………………………………………………………………...18 Chapter 3 Patient notes………………………………………………………………………….28 Chapter 4 Differential diagnosis Of important presentations…………………………………………..….……………34 Chapter 5 Closure and counseling………………………………………………………………44
  4. 4. 4 The Exam The exam is in the form of 11 or 12 cases in which you are requested to take history and do physical exam on each case in 15 minutes period and then to write the patient notes including the history , physical exam , differential and workup in 10 minutes. You are allowed only to have a white coat, a stethoscope and what you will eat during the breaks into the exam area. The day starts at 8am for morning session and 3pm for the afternoon session so it is better to be at the exam center at 7:30 and 2:30 respectively. The day start by an introduction about the exam and demonstration of the tools that is used in the exam rooms during the encounter, please feel free to use all the equipments during the demonstration so you can feel comfortable while using them during the encounters. At 9am and 3pm the sessions begins with every doctor standing in front of an examination room with the patients notes written on the door, you are not allowed to see the patient notes until you hear the announcement that you can start the encounter then you knock and enter the room. The encounter last for 15 minutes during which you have to take a focused history and do a focused physical exam, then after leaving the room you will be given 10 minutes to write the patient notes (history , physical , differential and workup) Of the 11 or 12 cases only 10 cases will be marked and the marks will be determined by 3 components: Integrated clinical encounter (ICE) which contains data gathering and patient notes, Communication/interpersonal skills (CIS), Spoken English proficiency (SEP). The score that you receive for the CS will be either “PASS” or “FAIL”.
  5. 5. 5 STUDY TIPS 1- Practicing the cases is the most important single strategy to pass the exam. The time constraints during the encounter and writing of patient notes makes practice so important so you do not have to think about every question and examination technique and note to write, all will become a routine that you will feel more confident during the encounter and spare your mind for better communication with the SP the area that most IMG’s have the biggest problem at. 2- Studying of the mental check list of each case that you practice is very important so not to miss a question in the history taking or a special examination for one of the differential diagnosis. 3- Study groups where you can be the doctor and the SP in different cases will put you very close to the real exam and will uncover all your weakness points so you can work on before the real thing. 4- Dividing the history into 2 main sections: the HPI (history of present illness) and the PAM-HS-FOSS. Discussed later in details in the how to take a history. 5- Examination is divided into case related system focused exam, heart and lung auscultation and related general exam. Discussed later in details in how to make the physical exam. 6- Closure and counseling needs good practice for what to say and how to say it, through several study groups that I have been to, I found this to be a challenge to IMG’s and this will be greatly improved after you read the section on how to do closure and counseling. 7- Patient notes writing are better written from down-up. Discussed later in details in how to write patient notes. Remember:  The more you practice the better you will gradually be.  English is one third of the exam so practice the language well.  Communication skills and how you approach the SP is another one third and practicing patient approach and responding to challenging questions will secure you the points on the exam and in the real thing as well.
  6. 6. 6 CHAPTER ONE HISTORY
  7. 7. 7 SAMPLE of how you should divide your history and physical exam paper Example 1 MR ADAM 55 yo Vs WNL Mental check list 1- 2- 3- 4- HPI + ROS L I Q O R A A P A P A M H S F O S S Positives in physical exam Points to council the patient on at the end of the encounter
  8. 8. 8 Example 2 MR ADAM Mental check list: 50 yo 1- Vs WNL 2- 3- HPI + ROS L I Q O R A A P A P A M H S F O S S Positives in physical exam points to council patient on
  9. 9. 9 History taking Is divided into 3 main parts: 1- HPI (history of present illness) + ROS (review of systems) + History to think about. 2- PAM-HS-FOSS. 3- PSYCHIATRIC HISTORY. HPI 1- Analysis of the CC which is divided into: -PAIN LIQOR-F-AAPA stands for (location, intensity, quality, onset course duration, radiation, frequency, alleviating factors, aggravating factors, ppt event and associated symptoms) -ANY OTHER CC OCD-F-AAPA stands for (onset, course, duration, frequency, aggravating, alleviating, ppt event and associated symptoms). HISTORY TO ASK IN SPECIFIC CASES: 1- ANY FLUIDS (sputum, blood, discharge, vomiting) amount (teaspoon, tablespoon or cup full), color, odor, if not blood whether it contains blood or not, vomiting (projectile or not?), bleeding per rectum (bright red or mixed with stools?). 2- MUSCLOSKELETAL swelling, redness, morning stiffness, pain in other joints, bone fractures, numbness, tingling and weakness. 3- ENURESIS nights/week, episodes/night, amount/episode and particular time during the night + stresses, environmental changes, sleep apnea (snoring, night awakening), interventions and drugs tried. 4- CONFUSION OR FORGETFULLNESS problems with the DEATH- SHAFT stands for (dressing, eating, ambulating, toileting, hygiene, shopping, housekeeping, accounting, food preparation, transportation). 5- EAR SYMPTOMS hearing loss, vertigo(sensation of room spinning or feeling of imbalance), tinnitus, discharge, pain. 6- CHRONIC DISEASE FOLLOW UP(DIABETES & HTN) OCD + ROS + controlled or not, last measurement, medications ( current, previous eg.insulin in diabetes, compliance, doses, sideffects), side effects of disease (retinopathy, stroke, nephropathy, intermittent claudication, angina, MI) 7- INSOMNIA 4D-N-4S (Daily sleep habit, Duration of sleep, Difficulty falling asleep, Difficulty staying asleep, Night mares, Snoring, Sleepiness during the day, Smoking or alcohol or coffee before sleep, Seeing TV in bed)
  10. 10. 10 8- SEIZURES ABCD, Aura (signs that the attack will happen), Bowel/bladder control, Bite tongue, Consciousness lost, Confusion after regaining consciousness, Describe it. 9- AMENORRHEA .Hot flushes, vaginal dryness/itching (Menopause/premature ovarian failure) .Nipple discharge, visual changes, headaches (Hyperprolactinemia) 10- DOMETSTIC VIOLENCE are you Safe at home? is there Threat to your personal safety at home or any where else? does Any one threatens or hurts you or your children? can you tell me about these Bruises?, any family Members know about the abuse?, do you have an Emergency plan? Child abuse at home? Other injuries? Weapons at home? Regular abuse? Drinking problems for the abuser? 11- PEDIATRIC CASES ask about the following histories  BIRTH HISTORY: full term, regular antenatal care, pregnancy u/s, complications during pregnancy, normal or cs delivery, first bowel movement.  DEVELOPMENTAL HISTORY: “ is his weight, height, language development normal?”  DIETARY HISTORY: breast feeding, fortified formula, solid foods, multivitamins.  IMMUNIZATION HISTORY: “is he up to date on his immunizations?” “When was his last checkup? 12- FATIGUE Progression during the day, Performance/job affected or not 13- HEADACHE LIQOR-F-AAPA, Aura(signs that the attack will occur?), visual changes/tearing/runny nose during the attack, relation to menstruation, wake you up from sleep?. 14- ERECTILE DYSFUNCTION severity on 1-10 scale (1 for flaccid, 6 for adequate for penetration), libido, nocturnal or early morning erections, marital problems, depression, anxiety, buttock or leg pain when walking or resting. 15- WEIGHT GAIN hypothyroid symptoms, depression, PCOS (hirsutism, irregular cycles), Pseudo tumor cerebri (headache, visual changes) 16- DYSPARUNIA LIQOR-F-AAPA, CD-PPP, libido, marital problems, depression, anxiety, h/o STDs, premature ovarian failure(hot flushes, vaginal dryness/itching) 17- BACK PAIN urinary of fecal incontinence, TB symptoms (fever, night sweats, wt loss) 18- DIARRHEA OCD-F-AAPA, Relation to oral intake, Regular bowel movements before. Pediatric: number of wet diapers and vigorous cry (to assess dehydration), recent URI, day care center.
  11. 11. 11 19- HEARING LOSS Ear symptoms, exposure to loud noises, insertion of foreign bodies, neurological problems (weakness, numbness, tingling), severity(mild, moderate, severe) 20- DIFFICULTY SWALLOWING OCD-F-AAPA, exact Location, Liquids or solids or both (if both which first?) 21- FREQUANT FALLS Movement problem (initiating, stopping), Injuries, Living conditions (support at home) 22- VOMITING Amount, Color, Odor, Blood, Content, Projectile or not? 23- JAUNDICE OCD-F-AAPA, color of stool and urine, itching/pruritis, blood transfusion, bleeding tendency, sore throat. 24- BLEEDING PER RECTUM OCD-F-AAPA, 3C-MBA, bright red or mixed with stool. 25- BLURRED VISION OCD-F-AAPA, neuro, Discharge, DM symptoms (excessive thirst, urination, wt loss and/or eating), Halos around the lights(cataract, glaucoma), Loss of vision completely before. 26- POLYURIA OCD-F-AAPA, BUN-FSH-2P, Thirst, Water intake, Volume of urine. 27- RASH OCD-F-AAPA, initial location and progression, initially flat or raised and if changed, Pruritis, Pain over the rash, Pain in joints, Animal contact, Insect bite. 28- SMOKING COUNSELLING 1- Habit: when? Why? How much? Stress? Concerned about your health? Like it? 2- Problems: ROS 3- Counseling: see later in details. 29- ALCOHOL COUNCELING 1- Habit: When? Why? How much? Stress? Concerned about your health? CAGE? 2-Problems: ROS. 3-Counseling: see later in details. 30- DIZZINESS OCD-F-AAPA, what you Mean (room spinning around you or you spinning inside)?, Tendency to fall and to which side, relation to Posture. 31- KNEE TRAUMA Noise at time of injury (popping sound for ACL injury), uNstability of the joint, uNlocking and locking of the knee (meniscal injury). 32- SICKLE CELL ANEMIA AND PAIN attack crisis (diarrhea, dehydration, infection, environment causing shortness of breath) 33- SORE THROAT OCD-F-AAPA, URT symptoms, Joint pain, Vaginal discharge.
  12. 12. 12 34- BURNING URINATION IN YOUNG FEMALE OCD-F-AAPA, CD-PPP (for vulvovaginitis, PID). 35- DRUG REFILL OR FOLLOW UP HTN DM HIV 1- disease: OCD 2- Medications: what? Doses? Compliance? Side effects? Other drugs in the past? 3- Monitoring: regular follow ups? How often? Last measurement? 4- Complications: HTN, DM ROS HIV ROS, oral white patches, motor/sensory problems, depression, informed sexual partner or not. 37- FIRST PRENATAL VISIT CD-PPP, how did you know? Blood transfusion? Previous birth problems? Recent immunization? 38- CHILDWITH FEVER OCD-F-AAPA, how high? Last measured? Chills/sweating? Medications? ROS, birth/developmental/dietary/immunization histories.
  13. 13. 13 2-Schematic drawing for associated symptoms to ask specific to the system of the CC: ABDOMEN RESPIRATORY AND CARDIAC
  14. 14. 14 NEUROLOGICAL OB/GYN (CD-PPP)
  15. 15. 15 ROS History to think about These are important points in different cases that are commonly missed, you will not necessarily ask all of them in every case but you should think about them and ask what is relevant to the case. 1-Trauma. 2-Travel. 3-Testing for TB or Exposure to TB. 4-Testing for HIV (as in high sexual risk practice e.g. Multiple sexual partners or homosexual or sore throat cases). 5-Sick contacts (ie, sick contacts at day care center). 6-Screening tests (as in terminal cancer case). 7-Rash. 8-Vaccines ( as in over 50 patients and pediatric cases)
  16. 16. 16 PAM-HS-FOSS P Past history similar problems. Past history of medical problems. A Allergies. M Medications (prescription and over the counter). H Hospitalizations and past surgical history. S Sleep problems. F Family history (similar problems, parents alive, medical problems) O OB/GYN ( this is asked in case of a female and the CC is not related to OBGYN, so, only ask about LMP and whether cycles are regular or not) S Social history (diet,appetite,weight / smoking,alcohol,illicit drugs / occupation,exercise,family stress). S Sexual history (sexually active? Who is your partner? If not his wife ask do you use any method of contraception? If condoms, ask used regularly or not?)
  17. 17. 17 Psychiatric history Is divided into: 1- HPI = TT-DSM-FAWR + ROS 2- PAM-HS-FOSS Think what do you think your problem is related to? Thyroid cold or heat intolerance, voice change, tremors, hair fall, Palpitations. D Duration of symptoms. Daily routine Delusions and hallucinations (do you see or hear things that others don’t?) S Support (do you have someone to talk to when depressed?) Suicide (considered ending your life? Plan? Guns or pills at home?) Sense of guilt. M Mood (what has been your mood lately?) Memory (do you have problems remembering things?) MMSE (discussed in details in neurological exam) F Feeling lonely (have you been feeling lonely lately?) A Anxiety (have you been feeling anxious lately?) WR Realize (do you realize you have a problem?) Willing (are you willing to get help?) Mnemonic for the depression symptoms: SIG-ME-CAPS (all covered within the general scheme) Sleep, Interests, Guilt, Mood, Energy, Concentration, Appetite, Psychomotor agitation or slowing, Suicidal ideation.
  18. 18. 18 CHAPTER TWO PHYSCIAL EXAMINATION
  19. 19. 19 Physical exam The examination room is equipped with all the instruments that you are suspected to use during the physical exam, and these are: 1. Ophthalmoscope. 4. Cotton tips, tooth picks. 2. Otoscope. 5. Tongue depressors 3. BP cuff and monitor. 6. Tuning fork, hummer. The physical exam is divided into: 1. General exam. 2. Systems examination. 3. Miscellaneous examinations. General examination These examinations are not necessarily done routinely in every case, but you should think about them and do what is relevant to the case. Head Tender sinuses. Eye Conjunctive for pallor. Fundoscopic exam. Nose For nasal discharge. Throat Pharyngeal injection and tonsillitis. Ear Ear discharge. Otoscope. Neck LNS. Thyroid + reflexes + hand tremors. Carotid bruit auscultation.
  20. 20. 20 Extremities Pulsations (radial and dorsalis pedis) LL edema. Skin. Systems examination Chest examination: (patient sitting or lying down) 1. Inspection: Distress Depth,rhythm,rate Deformity. 2. Palpation: Trachea Tenderness TVF Thumb-expansion Tachycardia(PMI). 3. Percussion. 4. Auscultation: if TVF +ve do bronchophony and whispering pectoriloquy (ask the patient to say 99 loud and while whispering while you are auscultating) Cardiovascular examination: (sitting lying down sitting again) A. Sitting: PULSE Carotid + bruit Radial Pedal + edema B. Lying down: 1- Inspection, palpation: Pulsation of jugular vein at 30 degree. Pulsations (aortic, pulmonary, sternal) PMI (LIQ location, inch, quality) 2- Auscultation: 4 areas (aortic, pulmonary, mitral and tricuspid) C. Sitting: Auscultate the 4 areas.
  21. 21. 21 Abdominal examination: (lying down) 1. Inspection: Swelling Scar Pulsations Peristalsis. 2. Auscultation: Bowl Bruit 3. Percussion: 4 quadrants. Liver (MCL up down and down up) Spleen (last intercostal space AAL deep breath percuss again dull=splenic enlargement) Shifting dullness. 4. Palpation: Superficial (watch the SP face) Deep palpation. Liver Spleen 5. Special exam: Tenderness Rebound (pain on releasing hand), done if tenderness on palpation. CVA (pain on CVA percussion) Suprapubic tenderness. Signs Psoas sign (extension of Rt hip in left lateral position causes pain in appendicitis) Obturator sign (flexion of Rt hip with internal rotation cause pain in appendicitis) Rovsing’s sign (deep pressure in LLQ causes pain in RLQ in appendicitis) Murphy’s sign (on deep palpation of the RUQ with inspiration pain occur and patient stop breathing) N.B: Tell the SP that you will need to do inguinal/rectal exam if male and pelvic/rectal exam for female as these are forbidden during the exam.
  22. 22. 22 Neurological examination: 1- Mental status : can be done at end of the history, beginning of physical or end of physical exam. Orientation tell me your full name? where are we? What day it is? Memory SHORT I will say 3 words and I want you to repeat them(pen, pencil, car) immediately and after 5 minutes so please remember them. LONG who was the previous president of the states? Abstraction could you please say the word “WORLD” backward. Judgment please take my pen with you right hand put it in your left hand and give it back to me. 2- Cranial nerves: Optic cover each eye and count fingers. Eye movements (3,4,6) Trigeminal palpate the masseter while the SP clinching his teeth. Facial close your eyes please and don’t let me open them. can you smile please. Vestibulocochlear rub your fingers near the patient ears to see if he hears it. Vagus and glossopharyngeal please open your mouth and say”AH” Accessory please shrug your shoulders (against hand resistance) Hypoglossal please stick out your tongue and move it form side to side. 3- Motor: a. Muscle tone: “I would like to examine your muscle tone, please relax your muscles, ok?” Flex and extend the wrist and elbow, knee and ankle. b. Muscle strength: “I would like to examine your muscle power, ok?” “pull in and push out maneuvers”
  23. 23. 23 4- Sensory: “I would like to check sensory perception in different areas of your body, ok?” a. Light touch(cotton), Pain(tooth pick): “This is dull and this is sharp, please close your eyes and tell me whether its dull or sharp when I touch you?” b. Vibration, position: Done if abnormalities in light touch and pain. Tuning fork placed on/change in position of DIP of index finger and big toe. c. Special tests for meningitis: Neck stiffness flexion of patient’s neck causes pain. 5- Reflexes: “I would like to check your jerks, please relax your muscles?” UL Triceps, Biceps(tape on your finger), Brachioradialis. LL Knee, Ankle + Babinski 6- Cerebellar function: “I would like to check your balance and movement, ok?” a. Gait: GET UP AND GO TEST “please get up and walk toward the wall and back” b. Romberg’s test: “please stand with your feet together and arms extended, close your eyes I wont let you fall” c. Finger to nose test: “please extend your arm then touch your nose, now do it while your eyes are closed” Grading of muscle power: Grading of reflexes: 5/5 normal 0 absent 4/5 less than normal 1 hyporeflexia 3/5 not against resistance 2 normal 2/5 not against gravity 3 hyperreflexia 1/5 flicker 4 hyperreflexia + clonus 0/5 absent
  24. 24. 24 MISCELANEOUS EXAMINTAION A- EYE EXAMINATION: 1. Conjunctiva : “please look upwards” while you are pulling the lower lids downwards. 2. Count fingers: “please put your Rt hand on your Rt eye and count my fingers”. 2. Movement of extra ocular muscles : “please follow my finger to examine your eye movement”. Lt thumb on the chin to fix the head and the Rt index moves in the 3 cardinal positions on the Rt and vice versa. 3. Fields examination : (remove your glasses) done in 2 ways: “please close your Rt/Lt eye and tell me how many fingers do you see/when you see my finger”  Counting fingers ask the patient to close one eye and you close the opposite one and then use both hands to make counting fingers in both temporal and nasal fields, upper and lower quadrants.  Moving finger as above but instead of counting fingers move your index fingers from outward inwards in both fields and both quadrants. 4. Fundus examination : (remove your glasses) “I will now dim the light to examine your retina please look straight ahead” use the Rt hand and Rt eye to examine the patient’s Rt eye and vise versa.
  25. 25. 25 B- MUSCULOSKELETAL EXAMINATION: 1- Inspect and compare (don’t forget the back of the areal you examine) Appearance Atrophy Deformity Swelling Redness 2- Palpate and compare Temperature Motion range Pulsations Tenderness Motor, sensory, reflexes Special situations: 1- UPPER EXTREMITY PAIN  Neck range of motion.  Adson’s test (palpate radial pulse while the patient extend his neck to the opposite side for thoracic outlet syndrome)  Tinel test (Tap median N. on wrist for carpal tunnel syndrome)  Phalen test (Flex wrist for carpal tunnel syndrome) 2- BACK PAIN  Spinal and Para spinal tenderness (lumber strain)  Straight leg raising test (lumbar disk prolapse, L4-decreased knee jerk, L5-decreased big toe dorsifexion, S1-decreased ankle jerk)  Eye examination for uveitis (ankylosing spondylitis) 3- DVT homan’s sign (dorsifexion of foot produces cuff pain), in cases of chest pain, dysnea and LL pain. 4- EYE EXAMINATION in cases where uveitis may occur ( back pain, rash, wrist pain, knee pain) 5- KNEE TRAUMA examine for: Drawer, McMurray’s, Effusion. 6- IN ANY JOINT PAIN examine the joints of the hands.
  26. 26. 26 B- EAR EXAMINATION: 1. Inspect and palpate + mastoid “please tell me if you feel pain” 2. Hearing :  Whisper “please cover your Lt/Rt ear” whisper in the other ear with pen/light and ask the SP to repeat.  Rene test (normally AC>BC, positive)  Weber test (normally no lateralization, negative) 3. Otoscope exam: rest your hand on the mastoid process. C- NOSE EXAMINATION: 1. Inspection: “Please tilt your head backward” use the otoscope as a light pen to examine the nose. 2. Sinuses examination: “I will press on your face, please tell me if you feel pain.” Frontal Ethmoid Maxillary D- THROAT EXAMINATION: “Please open your mouth and say AH” use a tongue depressor. “Please stick out your tongue” inspect upper and under surface. N.B: ENT are always examined together. E- NECK EXAMINATION: 1. Inspection: Swelling Scars Symmetry 2. Palpation: Tenderness Thyroid anterior approach: press on one lobe with your fingers while you examine the other from inside out toward the sternomastoid with the thumb. Posterior approach: examine both lobes together in a rolling movement while the SP swallows. 4. Lymph nodes: Posterior occipital post auricular anterior auricular submandibular submental superficial and deep cervical supraclavicular N.B: forbidden examination (not done but tell the SP you will need to do them if indicated) female breast, pelvic, rectal, genital, corneal reflex and inguinal hernia examination.
  27. 27. 27 F- EXAMINATION IN SPECIAL SITUATIONS:  If PE in DD (SOB and/or Cough) calf tenderness.  Difficulty swallowing give the patient water and ask him to swallow.  Motor vehicle accident (MVA) HEENT, chest, heart, abdomen, neurological (mental status/cr N./motor/sensory), skin for lacerations.  Hearing loss examine: ENT, Fundoscopic exam (papilledema), neurologic (cr n., motor, sensory, reflexes, Cerebellar)  Insomnia: Throat, Neck for thyroid+reflexes, listen to the heart, palpate abdomen.  HTN drug refill must record BP in both arms.  Any case with malignancy in DD examine for enlarged LNS.  Constipation Motor, Sensory, Reflexes in the LL.  DM drug refill FOOT EXAMINATION.  If the case is not a neurological case and you have neurological diseases in DD examine Motor, Sensory and Reflexes, if your timing is tight at least examine for Reflexes.
  28. 28. 28 CHAPTER THREE PATIENT NOTES
  29. 29. 29 PATIENT NOTES sample of the exam paper Patient notes are written from the bottom to the top starting with the differential diagnosis diagnostic work up physical exam history. Maximum of 5 DD and 5 diagnostic work up. History Physical examination Differential diagnosis Diagnostic workup: 1. 1. 2. 2. 3. 3. 4. 4. 5. 5.
  30. 30. 30 WRITING THE PATIENT NOTES HISTORY:  General format of the HPI: … Yo F/M c/o …., LIQOR-F-AAPA or OCD-F-AAPA, patient recalls/associated with ………, patient denies/not associated with…….  Points to be covered in the history are:  HPI, ROS, PMH, PSH, ALLERGY, MEDICATION, FH, OBGYN,SH, SxH.  History to be added in pediatric cases:  BIRTH H, DEVELOPMENTAL H, IMMUNIZATION H, FEEDING H.  History documentation in PSYCHIATRIC CASES: A-DSM-PTCI A Appearance. Affect mood congruent. D Delusions and hallucinations Duration. S Suicide. Speech scant or excessive, goal oriented or not. M Mood MMSE P Past traumatic event. T Thyroid. C Concentration. I Insight (does the patient realize he has a problem).
  31. 31. 31 PHYSICAL EXAMINATION: Normal in physical examination: VS (vital signs): WNL HEENT (head,eye,ear,nose,throat) :  Normocephalic, atraumatic, no bruises (in trauma or domestic violence)  Nose, mouth and pharynx WNL (in case of URI)  PERRLA(pupils equal round reactive to light and accommodation), EOMI(extra ocular movement intact), no Fundoscopic abnormalities, no nystagmus.  No cerumen, TMs normal, + rene, - weber, no tenderness (for ear exam).  Rash: multiple circumscribed erythematous lesions, no pigmentation, scales or jaundice noticed. NECK:  Supple, no lymphadenopathy (head and neck infections or metastatic cancer).  No JVD, no carotid bruit (in cardiovascular examination) HEART:  Apical impulse not displaced, RRR (rhythm,rate,regular), normal S1 and S2, no murmurs, rubs or gallops. CHEST:  No tenderness, clear breath sounds bilaterally, no rales, wheezes or ronchi, trachea central, tactile fremitus normal. ABDOMEN:  Soft, non distended, non tender, +bowel sounds, no organomegaly. ( S/ND/NT/+BS/no organomegaly) NEURO:  Mental status: alert, orientedx3, spells backward, recall 3 objects.  Cranial nerves: 2 to 12 intact  Motor: 5/5 upper and lower extremities.  Sensory: intact to touch and pinprick.  DTRs: 2+ symmetric in upper and lower extremities, - babinski.  Cerebellar: - Romberg, gait normal. EXTREMITIES:  No clubbing, cyanosis or edema.  Pulses 2+ and symmetric.  No tremors.
  32. 32. 32 OB/GYN:  G…P..., LMP…, regular/irregular, painful or not, bleeding or not (postcoital and/or intermenstrual), discharge or not, no history of abnormal pap smear. MUSCLOSKELETAL:  No warmth or erythema, no tenderness, normal range of motion, motor/sensory/reflexes, pulsations DIAGNOSTIC WORKUP: 1- Forbidden examinations. 2- CBC with differential. 3- Blood tests. 4- Radiological tests. 5- Special tests. 6- complications of the disease (ie obesity glucose, cholesterol, TGs), diarrhea electrolytes) 7- Age related screening test.  Electrolytes are a common investigation to order.  Similar tests could be written in the same line. DIAGNOSTIC WORKUP IN SPECIAL CASES:  Diabetic patient blood glucose, Hb A1C and urinalysis for microalbuminuria  Drug abuser serum and urine toxicology screens.  Diarrhea rotavirus enzyme immunoassay, Stool leukocytes, culture, ova, parasites and PH, AXR, electrolytes, cl. Difficile toxin.  Hearing loss audiometry, tympanometry, brain stem auditory evoked potential, VDRL or RPR(syphilis cause menier’s), CT head.  Back pain XR lumber sine, MRI lumber spine, PSA, Calcium, BUN/CR, serum and urine protein electrophoresis. (Multiple Myeloma).  Any neurological or psychological case electrolytes, serum and urine toxicology screen.  Any cardiological case, DM and HTN Lipid profile.  Enuresis genital exam, renal US, UA and culture, first morning urine specific gravity.  Shortness of breath CXR, ABG, pulse oximetry, sputum gram stain, AFB and cultures.  Any bleeding Postural BP and HR measurement, PTT/PT/INR, BMP (Na, K, co2, CL, HCO3,PH).  Impotence TSH, PRL, Testosterone, Nocturnal penile tumescence test.  Any DD with peptic ulcer H.plyori serology, upper GI endoscopy.  First prenatal visit TORCH screen, hepatitis B/C screen, HIV screen, Blood typing and grouping, UA and culture, abdomen US.
  33. 33. 33 DIFFERENTIAL DIAGNOSIS:  Maximum of 5.  Written in descending order of likelihood.  Thyroid problems and drug induced disorder are common in DD.  Mostly will be diseases from the mental check. Any DD could be divided into systems and then categories: 1- Systems: neurological, chest, heart, abdomen, musculoskeletal and HEEENT. 2- Categories: functional, traumatic/mechanical, inflammatory/allergic, metabolic/endocrine, neoplastic, vascular/blood, psychological, drug induced. DD in cases like (bilateral leg pain, unilateral leg pain, bilateral arm/UL pain, unilateral UL pin…..etc) will be divide into: 1- Structures: skin, bone, muscle, nerves, arteries and veins. 2- Categories: as before.
  34. 34. 34 CHAPTER FOUR DIFFERENTIAL DIAGNOSIS OF IMPORTANT PRESENTATIONS
  35. 35. 35 DD OF IMPORTANT PRSENTATIONS: (The aim of this list is to help you make a DD in your mind before the encounter; it is not conclusive of all the DD of each symptom) CHEST PAIN: 1. Heart: MI, angina, pericarditis, arrhythmias. 2. Lung: PE, pleuritis, pneumonia. 3. Chest: costochondritis. 4. Esophagus: GERD, perforation, obstruction. 5. Aorta: dissection 6. Psychiatric: panic attack. ACUTE COUGH (<3weeks): 1. Common cold 2. Acute sinusitis 3. Acute bronchitis 4. Bronchial Asthma 5. PE 6. GERD 7. Pneumonia 8. Drugs: ACEI. ACUTE SHORTNESS OF BREATH: 1. PE 2. CHF 3. COPD exacerbation 4. Bronchial Asthma 5. Anxiety, Panic attack. 6. Pneumothorax. COUGH AND CHEST PAIN: 1. Pneumonia 2. Pleuritic pain 3. TB 4. Lung cancer 5. PE 6. GERD CHRONIC COUGH: 1. Posterior nasal drip 2. Chronic bronchitis 3. Bronchiectasis 4. TB 5. Lung cancer 6. GERD
  36. 36. 36 SORE THROAT: 1. Bacterial pharyngitis (streptococcus pneumonia, gonococcal, mycoplasma) 2. Viral pharyngitis 3. Posterior nasal drip 4. GERD 5. IMN 6. 1ry HIV HEMOPTYSIS: 1. Pneumonia 2. PE 3. Bronchiectasis 4. TB 5. Malignancy 6. Bronchitis 7. CT disease 8. Pseudohemoptysis. SICKLE CELL ANEMIA WITH CHEST PAIN: 1. Vaso-occlusive crisis chest syndrome 2. Pneumonia 3. Osteomyelitis (salmonella) 4. PE PALPITAIONS: 1. Cardiac: Arrhythmias, valvular disease, PE. 2. Metabolic: hypo or hyperthyroidism, Pheochromocytoma, Hypoglycemia. 3. Psychiatry: Anxiety, Panic attacks. ACUTE DIARRHEA (<4weeks): 1. Viral GE 2. Bacterial GE 3. IBD 4. IBS 5. Malabsorption 6. Cl difficile colitis 7. HIV CHRONIC DIARRHEA: 1. Osmotic: laxatives, malabsorption 2. Inflammatory: IBD, IBS, giardiasis 3. Secretory: infections, VIPoma, cholera 4. Motility: hyperthyroidism DIARRHEA (PEDIATRICS): 1. Rota virus 2. Bacterial diarrhea 3. Malabsorption 4. UTI 5. Sepsis 6. Intussusception
  37. 37. 37 CONSTIPATION: 1. Functional 2. Obstructive: cancer, intestinal obstruction 3. Metabolic: hypercalcemia, hypothyroidism, DM 4. Neurologic: stroke, MS, PN, spinal cord lesions 5. Medications: opiates, iron, anticholinergics VOMITING OF BLOOD: 1. Esophagus: varices, Mallory Weiss syndrome, cancer. 2. Gastric: PUD, gastritis, cancer. 3. Pseudohemoptysis NAUSEA AND VOMITING: 1. Gastroenteritis 2. Intestinal obstruction 3. Inflammation: PUD, Appendicitis, Pancreatitis, Pyelonephritis 4. Neuromuscular: GERD, DM 5. Intracranial: Malignancy, infection 6. Medications: Digoxin 7. Pregnancy 8. Anorexia Nervosa. RECTAL BLEEDING: YOUNG 1. Anal: fistula, fissure, hemorrhoids. 2. Rectal: gonococcal proctitis. 3. Colon: IBD, infective colitis, cancer, vascular ecstasies. OLD 1. Diverticulosis/Diverticulitis 2. Cancer 3. Angiodysplasia 4. Ischemic colitis DIFFICULTY SWALLOWING: OROPHARYNGEAL 1. Mechanical: zenckers diverticulum, laryngeal carcinoma 2. Neurological: CVA, MS 3. Muscular: myasthenia gravis, muscular dystrophy. ESOPHAGEAL 1. Cancer 2. Achalasia 3. Scleroderma 4. GERD
  38. 38. 38 DIFFICUTY WITH URINATION: 1. BPH 2. Prostatic carcinoma 3. Urolithiasis 4. UTI 5. Urethral stricture 6. Bladder cancer 7. Neurological: Spinal cord trauma, DM BURNING WITH URINATION: 1. Pyelonephritis 2. Cystitis 3. Uretheritis 4. Vulvovaginits 5. PID INCREASED URINATION: 1. DM 2. DI: neurogenic, nephrogenic. 3. Psychogenic polydypsia 4. UTI 5. Medications: diuretics 6. Hypercalcemia DARK URING (BLOODY URINE): 1. UTI 2. GN 3. Urolithiasis 4. Renal, ureteral or bladder cancer 5. Conjugated hyperbilirubinemia 6. Medications BILATERAL LEG PAIN: 1. Thromboangitis obliterans 2. Atherosclerotic vascular disease 3. Lumber spinal stenosis 4. Statins 5. Diabetic polyneuropathy 6. Radiculopathy. 7. Varicose veins UNILATERAL LEG PAIN: 1. Cellulitis 2. DVT 3. Ruptured backer’s cyst 4. Osteomyelitis 5. Traumatic. 6. Varicose veins
  39. 39. 39 BACK PAIN: 1. Lumber disc prolapse 2. Lumber muscle strain 3. Lumbar spinal stenosis 4. Osteoporosis 5. Degenerative arthritis 6. Multiple Myeloma 7. Spinal metastasis 8. TB of the spine “pott’s” 9. Ankylosing spondylitis KNEE PAIN AND SWELLING: 1. Trauma 2. Osteoarthritis 3. Septic arthritis 4. Lyme disease 5. Mono articular RA 6. Gout 7. Pseudo gout 8. Reactive arthritis 9. Psoriatic arthritis SHOULDER PAIN: 1. Dislocation 2. Fracture 3. Rotator cuff tear 4. Subacromial bursitis 5. Ligamental strain UPPER EXTREMITY PAIN: 1. Cervical disc prolapse 2. Cervical spondylitis 3. Thoracic outlet syndrome 4. Tenosynovitis 5. Carpal tunnel syndrome 6. Trauma HEAL AND FOOT PAIN: 1. Planter fasciitis 2. Calcaneal periostitis 3. Calcaneal spur 4. Painful heel pad syndrome 5. Stress fracture RASH: 1. Infectious: impetigo, rubella, measles among others 2. Insect bite 3. Allergic 4. Autoimmune: RA, SLE 5. Photo dermatitis 6. Occupational exposure
  40. 40. 40 MULTIPLE BRUISES: 1. Accident 2. Domestic violence 3. Bleeding disorder 4. Autoimmune collagen vascular disease IMPOTENCE: 1. Vascular: atherosclerosis 2. Neurological: DM neuropathy, spinal cord lesion 3. Endocrinal: pituitary lesion, medications 4. Psychiatric: anxiety, depression INSOMNIA: 1. Medical: COPD, CHF, PUD, hyperthyroidism 2. Psychiatric: anxiety, depression, PTSD 3. Sleep apnea 4. Irritable leg syndrome 5. Circadian rhythm disorder 6. Menopause 7. Medications 8. Malignancy FREQUENT FALL: 1. Parkinsonism 2. Cerebellar lesions 3. Seizures 4. Vertigo 5. Orthostatic hypotension: e.g. DM 6. Vascular: TIA SEIZURES: 1. Trauma 2. Infection 3. Medication induced or withdrawal 4. Metabolic 5. Vascular: e.g. Stroke 6. Tumor 7. Hypoglycemia 8. Syncope 9. Intoxication ARM AND LEG WEAKNESS: 1. Stroke 2. TIA 3. SDH 4. SAH 5. Guillan Barre syndrome 6. Complex migraine 7. Conversion disorder
  41. 41. 41 HEADACHE: 1. Primary: Migraine, cluster headache, tension headache 2. Secondary: Extra cranial Glaucoma, errors of refraction, OM, temporal arteritis, sinusitis, dental disease, cervical spine lesion Intra cranial Infection (meningitis, encephalitis), SAH, tumor, pseudo tumor cerebri CONFUSION: 1. TIA and stroke 2. Dementia: Alzheimer’s, multiinfarct dementia 3. Depression 4. Metabolic: hypothyroidism, hypoglycemia 5. Medications 6. Infections: meningitis, encephalitis DIZZINESS: 1. Neurological: infections, vascular, tumor, traumatic, migraine 2. Cardiological: AS, arrhythmia, HOCM, acute coronary syndrome 3. Ear diseases: OM, menier’s, benign positional vertigo, labyrinthitis 4. Metabolic: hypoglycemia, hypothyroidism, anemia 5. Panic attacks 6. Orthostatic hypotension SPELLS OF LOC: 1. Neurological: TIA, stroke, seizures, migraine 2. Cardiac: arrhythmias, CAD, AS, HOCM 3. Psychiatric: conversion disorder 4. Vasovagal attack 5. Orthostatic hypotension BLURRING OF VISION: 1. Diabetic neuropathy 2. HTN neuropathy 3. Cataract 4. Glaucoma 5. Temporal arteritis 6. Infection: uveitis, optic neuritis, orbital Cellulitis 7. Brain lesions: optic glyoma, occipital lobe lesions
  42. 42. 42 HEARING LOSS: Conductive FB, cerumen impaction, TM perforation, post OM effusion, otosclerosis, cholesteatoma Sensorineural Presbycusis, noise induced, ototoxicity, menier’s disease, acoustic neuroma NOSE BLEED: 1. Trauma 2. Bleeding tendency 3. Nasopharyngeal angiofibroma 4. FB 5. Wegner’s granulomatosis 6. Medication induced 7. Thrombocytopenia AMENORRHEA: 1. Pregnancy 2. Hypothyroidism 3. Prolactinoma 4. PCO 5. Stress induced: excessive exercise 6. Anorexia nervosa HOT FLASHES: 1. Menopause 2. Premature ovarian failure 3. Hyperthyroidism 4. Carcinoid syndrome 5. Chronic fatigue syndrome 6. Occult malignancy 7. Factitious disorder VAGINAL BLEEDING: 1. Regular menses 2. Abortion 3. Ectopic pregnancy 4. Hydatiform mole 5. Malignancy: endometrial, cervical and estrogen producing endometrial cancer 6. Traumatic 7. Bleeding tendency
  43. 43. 43 CHILD WITH FEVER: 1. Respiratory tract infection 2. OM 3. Exanthematous disease 4. Meningitis 5. Encephalitis 6. UTI 7. GE CHILD WITH VOMITING: 1. GE 2. Intestinal obstruction 3. GERD 4. Pyloric obstruction NIGHT SWEATS: 1. Infections: TB, HIV 2. Malignancy: Lymphoma 3. Endocrine: Hyperthyroidism, Pheochromocytoma 4. Medications ENURESIS: 1. Primary nocturnal enuresis 2. Secondary enuresis 3. UTI 4. Constipation 5. Sleep apnea FATIGUE: 1. Occult malignancy 2. DM 3. TB 4. HIV 5. Depression 6. Hyperthyroidism 7. Malabsorption 8. Addison’s disease 9. Anemia
  44. 44. 44 CHAPTER FIVE CLOSURE AND COUNCELLING
  45. 45. 45 ENRANCE, CLOSURE AND COUNSELLING ENTRANCE?  Knock and enter  You: “Hallo Mr/Mrs …… I am dr ….. I am ……, are the room settings comfortable?”  SP: “yes”  You: “ok Mr/Mrs …… how may I help you?”  SP: “I have back pain”  You: “oh I am so sorry to hear that, ok Mr/Mrs ….. First we will talk about your problem then I will need to do a brief physical examination and I will be as fast and as gentle as possible, ok?”  SP: “ok doctor, thank you”  You: “could you tell me more about your problem please?” GERNERAL COUNSELLING:  You: “Thank you Mr/Mrs …… for your cooperation, let me give you my impression, you told me you have …..(give a very short to the point briefing of the history)… is that right”  SP: “yes”  You: “and from the physical exam, I am thinking your problem may be related to ….(give the most likely disease)… which is …..(give brief explanation)…. But we can not be sure yet we will have to run some tests first, then I will sit with you again to explain the results, tell you the final diagnosis and agree on a management plan, is that ok?”  SP: “yes doctor”  You: “do you have any questions or concerns?”  SP: will give you the challenging question if he hasn’t already or will say “no doctor thank you”  Shake hands saying “it was nice meeting you, I will do my level best to help you” and leave the room.
  46. 46. 46 COUNSELLING IN SPECIAL SITUATIONS: COUNSELING IN DOMESTIC VIOLENCE: (spousal, child or geriatric abuse)  Mr/Mrs ……. I am concerned about your safety.  I am always available for help and support whenever you need it.  Every thing we discuss is confidential but I have to involve child protective services if your children are being abused.  We have a lot of resources to help you like support groups, I will give you their contact information, do you have any questions or concerns? COUNSELLING IN ENURESIS:  Don’t worry Mrs …… this is a common problem in children.  However it can be embarrassing to the child and stressful to the family.  Most cases can be treated with life modifications without the need for drugs, here what I want you to do: 1. monitor fluid/day 2. limit fluids before sleep 3. bathroom before sleep 4. wake 2-3 hrs after sleep to go to bathroom 5. make him/her change his/her pajamas 6. give reward for the dry nights 7. bedwetting alarm that rings at the beginning of bedwetting COUNSELLING IN OBESITY:  Restrict fatty food  Regular exercise  Radical change in diet habits is not recommended  Read books about obesity and loosing weight  Consult a dietitian SMOKING AND ALCOHOL COUNSELLING:  You: “Mr/Mrs …… I am concerned about your smoking/alcohol drinking, smoking causes a lot of health hazards like heart attacks, strokes, lung cancers, urinary cancers and stomach ulcers among users/alcohol cause a lot of health hazard like liver cirrhosis, pancreatitis, gall bladder stones and stomach ulcers among others, Are you willing to quit smoking/alcohol drinking?”  SP: “NO”
  47. 47. 47  You: “ok Mr/Mrs ….., I understand you are not ready now to quit smoking/alcohol drinking, when you decide to quit I will be here to offer you all the support you need, also, we have a lot of resources to help you quit through our social workers”  SP: “YES”  You: “I am glad you made that decision, I will be here to offer you all the support that you need, also, we have a lot of resources to help you quitting and I will make you an appointment with one of our social workers, ok?”  SP: “ok, thank you doctor” COUNSELLING IN ANY PSYCHIATRIC CASE SHOULD INCLUDE:  I am willing to talk to your family to be more supportive if you want.  I will be here to offer you all the support that you need during treatment. COUNSELLING IN PEDIATRIC CASES SHOULD INCLUDE:  Mrs ….. I am concerned about your child problem and I want you to bring him/her to the hospital as soon as possible to examine him/her and to order some tests, if you are not able to bring him/her to the hospital I can arrange someone to pick him/her up from home.  Meanwhile I would like you to …. (Give him Tylenol and cold compresses if he has fever for example)… COUNSELLING IN TERMINAL CANCERPATIENTS:  Mr/Ms….. I understand what you are going through. I will be giving you something to relieve your pain and I am always here to be of any support to you at any time.  I want you to be aware of things that will be necessary later on in your life: 1. Living at home or nursing home? 2. Hospice: completely supervised medical, psychological and physical support that is provided at home at terminal stages of disease to let patients live as comfortable, pain free and as full as life as possible. 3. Advance directive: living will that enable the patient to say how he or she want to be treated at terminal stages of his/her illness when no more able to make decisions.
  48. 48. 48 COUNSELLING IN DIAGNOSED OR HIGH RISK HIV CASES:  Safe sexual practice (use of condoms regularly, inform partner, avoid high risk sexual behavior like multiple partners)  Treatment, side effects and management  Vaccinations (only killed vaccines, e.g. Influenza, Hepatitis A)  Support system COUNSELLING IN DM:  Diet, exercise and medications COUNSELLING IN FIRST PRENATAL VISIT:  Work up: HIV consent, TORCH, blood typing and grouping, hepatitis screening.  Supplements: iron, vitamins, nutritious diet, calcium  Safe sexual practices  Regular antenatal visits COUNSELLING HEEL/FOOT PAIN:  RICE (rest for 3 days, immobilization, cold compresses 30min/d, elevation)  Ibuprofen  Avoid exercise or weight bearing  Soft heel pads  Padded foot splint during sleep

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