Professional Documents
Culture Documents
Location
4. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Is your pain constant or does it come and go? Quantity
How often do you have pain?How many times do you have pain
per day/week/month? (
How long does it last for each episode (every time)?
6. Now, if compare with the onset, is the pain getting worse or better? P
7. Does the pain move around or stay in one place? Radiation
8,
Does anything increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve (reduce)the pain? (Does anything make the pain better?)
Alleviation
.Association Besides your pain do you have any symptoms?
1. Did you notice any swelling or redness in your shoulder?
2. Did you feel tingling or numbness or loss your sensation?
3. Did you feel any weakness?
4. Did you have any change in your vision?
5. Did you have a sore throat ?
6. Did you have any change in your skin?
7. Did you have any pain in your other joints?
8. Do you have fever?
9. Do you have any heart problem?
Affect-Cause
10. Can you use your arm in your daily activities?
11. Do you think what is causing your pain?
PAM:Now I need to ask you a few questions about your health in the past. Is that OK
with you?
1. Have you had shoulder pain before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
H(sit)UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8 Have you had any change in your sleep patterns? S
FOSxS:
FH:
1. Does anyone in your family have pain in their joints like you?
2. Does anyone in your family have any other serious medical problem? (HBP,DM,
high cholesterol level) Are your parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per day/week?
How long have you drunk alcohol?)
5. CAGE :
Have you ever felt a need to cut down on drinking?
Have you ever felt annoyed by criticism of your drinking?
Have you ever had guilty feeling about drinking?
Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
Sensation
Im going to touch your arm lightly. Please close your eyes. Do you feel this .Is it the
same
Pulse:
I need to check the pulse in your arms
DTRs
Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
Other joints:I need to examine another joints
Pulmonary: I need to listen to your lungs. Please, take a deep breath for me.
CV : Could you lie back on the table. I need to listen to your heart.
C. Counseling:
1. Based on your information and the findings from your physical examination.
I think you might be having inflammation (or a trauma) of your shoulder..
2. However, there are also other conditions which could be causing your pain
Such as dislocation, fracture, injury of ligaments etc.
3. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
4. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options .
5. Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.
2.CASE 2: Elbow Pain:
A. History taking. Hello Sir, Mr. Wilson. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable
Dont shake) How can I help you today?
1.Can you tell me more details about your pain?
. LiqorAAA-OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
Where did you first feel the pain? (where did your pain begin?)
What were you doing when the pain began? What brings the pain on?
Does the pain begin suddenly or gradually?
If patient have the fall: (Do you have injure from the fall? can you
describe your fall? After the fall were
you conscious or unconscious? Does any one treat you badly at home?
Have you seen Doctor for that?
Why not?)
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten
is most) Intensity
3. Can you show me exactly where it is? Please (can you) point to where it hurt?
Location
4.
Tell me what the pain feels like? May you describe what kind of pain do you
feel like? Quality
Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Is your pain constant or does it come and go? Quantity
How many times do you have pain per day/week/month? (how often?)
How long does it last for each episode (every time)?
6. Now ,if compare with the onset, is the pain getting worse or better? P
7. Does the pain move around or stay in one place? Radiation
8. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve the pain? (Does anything make the pain better?)
Alleviation
Association
1. Did you notice any swelling or redness in your elbow?
2. Did you feel tingling or numbness or loss your sensation?
3. Did you feel any weakness?
4. Did you have any change in your vision?
5. Did you have a sore throat ?
6. Did you have any change in your skin?
7. Did you have any pain in your other joints?
8. Do you have fever?
9. Do you have any heart problem?
Affect-Cause
1. Can you use your arm in your daily activities?
2. Do you (know)think what is causing your pain?
PAM
1. Have you had elbow pain before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes
5. Are you allergic to anything? (Plants, food, medication..). (Do you have any
allergies?)
6. Do you take any medication?
Hsit UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FoSxS
FH:
1. Does anyone in your family have pain in their joints like you?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
2. Are you sexually active?
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having inflammation (or a trauma) of your elbow.
3. However, there are also other conditions which could be causing your pain.
Such as dislocation, fracture, injury of ligaments etc.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.
Alleviation
Association:
Digestive:
b. Have you had any change in your bowel movement? G
Have you had any stomachache?
Genito -urinary
a. Did you have any change in your urination? Did you have urinary incontinence?
Did you have burning in your urination?Did you have change in your urinary
frequency? Did you have change in urinary color(bloody, cloudy)
b. Did you notice any vaginal discharge? or vaginal bleeding?
Neuro-skeleto
c. Did you feel numbness or lose sensation in your legs?
d. Did you feel weakness in your legs?
e. Did you have any pain in other parts of your body? Joints, muscle pain?
f. Did you have fever?
PAM
1. Have you had back pain before?
2. Have you had any other medical problems? Example: high blood pressure,
high cholesterol, diabetes
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
5. Have you had any change in your weight recently? W (How many pounds did
you lose or gain? Over what period of time did it happen?) How long have you
been losing or gaining your weight?
6. Have you had any change in your sleep patterns? S
FoSx S
1. Does anyone in your family have back pain like you?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. .Do you notice any change in your period?
4. Have you had a Pap smear? When was the last Pap smear? What was the result of
the last time?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
How many sexual partners do you have?
2. Are they male or female or both?
3. Do you use any contraceptives?
4. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
*Challenging question:
1. Do I need surgery?
1.This is good question.
2. There are many conditions which could be causing your back pain.
3.Until now I really dont know what is causing your back pain
4.To have the exact cause. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to discuss your diagnosis and treatment options at that
time.
If your back pain can be treated by using medication, we will give you pain
medication first.
If your back pain can only be treated by surgery, then we have to proceed with
surgery
6. Please try not to worry because the staff and I are here to give you the best possible
care.
HSitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FoSxS
FH:
1. Does anyone in your family have leg pain like you?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
3. Are you sexually active?
4. How many sexual partners do you have?
5. Are they male or female or both?
6. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B. Exam component:
Extremities:
1. Caft tenderness
2. Homans sign
3. Pulses both legs and arms
4. sensation in both legs
5. DTRs, Babinskis sign in both legs.
6. color change & hair loss
7. raise Straight leg
Check spine:
CV: Heart: A
listen carotid
Lung:A
Abd:?? A Pa??
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Supine position
Legs
I need to uncover your legs and take a look in your legs
Lasegues sign:I m going to lift your legs up. Tell me if they hurts.
Calf tenderness: I need to press lightly on your caft.Tell me if you feel any pain or
discomfort
Homans sign : I need to flex your ankle Tell me if you feel any pain
Pulse:
1. Can I listen to your neck (carotid arteries), stomach (abdominal aorta).
2. I need to check the pulse in your arms and legs now.
Sensation
1 Im going to touch your legs lightly. Please close your eyes. Do you feel this .Is it the
same
2 This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)
Im done. Please open your eyes.
DTRs
3. I need to tap on your legs. (patellar, Archilles)
4. Now I need to tickle your feet lightly. (Babinski).
Standing position:
Veterbra Now, please stand up (DR have to pull out the footstool .) Please walk to
me.(toes & heel walking)
1. Im going to examine your back bone
2. I d like to take a look first.
3. I need to press lightly on your back. Tell me if it hurts.
4. Bend your body down and touch your toes with your fingers
5. Bend back.
6. Lean your body to the right.
7. Lean your body to the left.
Pulmonary: I need to listen to your lungs. Let me untie your gown.Please, take a deep
breath for me.
CV : Could you lie back on the table. I need to listen to your heart
C.Counseling:
1. Based on your information and the findings from your physical examination.
I think you might be having narrowing or obstruction of vessels in your leg.
2. However, there are also other conditions which could be causing your pain,
Such as problem in your vertebra or veins, etc .
3. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
4. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
1. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with low fat, low sugar (if he has had
diabetes)
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later
5.CASE26: Headache.
A. History taking. Hello Maam ,Ms.Wright. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can I help you today? Can you tell me more something about your headache?
LiqorAAA OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
a. Where did you first feel the pain? (where did your pain begin?)
b. What were you doing when the pain began? What brings the pain on?
c. Does the pain begin suddenly or gradually?
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is most)
Intensity
3.
4.
5.
6.
7.
Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
Was your pain continuous or does it come and go? Quantity
a. How often do you have headache? How many times do you have pain per
day/week/month?
b. How long does it last for each episode (every time)?
Now, if compare with the onset, is the pain getting worse or better? P
Does the pain move around or stay in one place? Radiation
Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve the pain? (Does anything make the pain better?) Alleviation
8.
Association:
a.
b.
c.
d.
e.
f.
CNS
g. Have you had any head trauma?
h. Have you had seizure?
i. Have you had weakness anywhere in your body?
j. Have you had tingling or numbness anywhere in your body ?
k. Have you had difficulty talking?
General
l. Do you have any fever?
m. Is your neck stiff?
Joints
n. Have you noticed another pain in you joint or your body?
Affect
o. Did your headache affect your daily activities (your job)?
PAM
1. Have you had headache before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
HSitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T Head trauma?
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did
you lose or gain? Over what period of time did it happen?) How long have you
been losing or gaining your weight?
8. Have you had any change in your sleep patterns? S ? Has your HD waken you
up from your sleep
FOSx S
1. Does anyone in your family have headache like you?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period
4. Did your HD relate with your menses(period)?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners use a condom all the time? (Do you use a condom
consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
* Challenging Question:
cancer?
1. This is good question
2. Headache is one of symptoms of brain cancer.
3. However, there are also other conditions which could be causing your headache,
and those conditions could be treated
Such as medication, Sinusitis, infection, tension headaches
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
6. Ill know if your problem could be cancer or not.
7. Please try not to worry because the staff and I are here to give you the best possible
care.
B.Exam component:
HEENT:Pa(head,sinuses,temporomandibular joints)
FO
I (nose, mouth, teeth, throat)
Neck exam: I, Pa
CV: A
Pulmonary: A
Abd exam: IAPaPe
Neurologic exam: Cranial nerves, muscle strength, DTRs
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
MRS
Please, Hold out your arms like this. Push up. Push down ( Shoulders)
Please, do this(elbow flexion). Pull in. Pull out.
Please, make the fists. Dont let me open them. ( Wrists).
Please, Spread your fingers apart. (Hands).
Please, Lift (Push) your thigh up. Lift (Push) your thigh down.( Thigh).
Please, Pull your legs in (flex your knee) and Kick your legs out (extend your knee).
Please, Lift( Push) your feet up (dorsal flexion ). Lift (Push) your feet down ( plantar
extension).
Reflexes: (R)
1. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
2. I need to tap on your legs. (patellar, Archilles)
3. Now I need to tickle your feet lightly. (Babinski).
1.
2.
3.
4.
5.
6.
7.
C.Counseling:
1. Based on your information and the findings from your physical examination.
I think you might be having Migrain headache (pain in one haft of the head and
occur with a few people in the same family), etc.
2. However, there are also other conditions which could be causing your headache,
Such as medication, Sinusitis, infection, tension headaches
To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
3. Once I get the results of these tests.
4.
Ill be in a better position to tell you your diagnosis and treatment options.
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later
Intensity
Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
4. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Was your pain continuous or does it come and go? Quantity
a. How often do you have chest pain? How many times do you have pain per
day/week/month?
b. How long does it last for each episode (every time)?
6. Now, if compare with the onset, is the pain getting worse or better? P
7. Does the pain move around or stay in one place? Radiation
8. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve the pain? (Does anything make the pain better?) Alleviation
Affect:
3. Do any of your activities affect your chest pain?
Association :
1. Do you have shortness of breath or difficulty breathing?
2. .Did you hear a racing of your heart?
3. .Did you have a cough? Is your cough or congested( Is there dry or productive
cough)? What does it contain? Is there blood in it? Do you notice a strong smell
(Does it smell foul)?
4. .Did you have any chest trauma?
Digestive:
1. Did you have nausea or vomiting?
Skeletal
2. Have you had pain ,swelling or redness in your legs? PE
General
3. Did you have any sweating( fever)?
3.
Sickle cell
4. Has any doctor said that you have a blood disorder?
5. Have you had a blood infusion?
6. Have you had the crises of sickle cell (a disease has abnormal red blood cell) after
diarrhea, dehydration, stress, heavy alcohol, heavy exercise, oxygen deficiency
(hypoxia)?
PAM
1. Have you had chest pain before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
Hsit UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. 28. Have you had any change in your sleep patterns? S
FoSxS.
FH:
1. Does anyone in your family have chest pain like you?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
*.Chanllenging question:
1. Am I having a heart attack? Am I going to die?
3. Until now I cannot rule out a possibility youre having a heart attack.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and
imaging studies.
5. Once I get the results of these tests.
6. And Ill know if your problem will be heart attack or not.
7. Please try not to worry because the staff and I are here to give you the best
possible care.
2. Until now I cannot rule out a possibility youre having a heart attack.
3. The strenuous activities, like hiking, place you at risk of getting a heart
attack.
3. Doctor, Will my problem be recurrent?
This is good question.
There are many conditions which could be causing your problem.
Until now I really dont know what is causing your chest pain
To have the exact cause. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
6. And Ill know if your problem can be recurrent or not.
1.
2.
3.
4.
7. Please try not to worry because the staff and I are here to give you the best possible
care.
B.Exam component:
Neck exam: JVD, carotid auscultation
CV: I Pa A
Pulmonary:I Pa Pe A
Abd exam: IAPaPe
Exts: Pulse, Edema
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is
that ok with you?
Neck: JVD, carotid auscultation
1. I need to check your neck area.
2. I need to listen to your neck. (the bruits of carotid arteries).
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. Let me take a look at your back.
3. Can you say 99 for me, please.
4. Im going to tap on your back to check your lungs. Is that ok with you?
5. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
6. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table
1. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
2. Im going to examine your heart. Let me uncover your chest.
3. I need to press in your heart area. (PMI).
4. I need to press in your chest. Do you feel any pain?
5. I need to listen to your heart.
6. Can you turn to your left side, please.
Sitting up
1. Can you sit up, and lean forward. Ill listen to your heart again.
Vascular
1. I need to check the pulse in your arms and legs now.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.
Extremities
1. I need to check for fluid retention in your legs.
C.Coumseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having the narrowing or obstruction of vessels in your heart.
3. However, there are also other conditions which could be causing your pain.
Such as diseases of the heart membrane, lung, chest wall, etc.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
5. To protect your health.
You shouldnt smoke or use alcohol
You should have a healthy diet, food with low fat, low salt.
You need a vaccination (H. influenza) to against pneumonia (sickle cell disease)
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.
Chest pain
1 LiqorAAA OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
a. Where did you first feel the pain? (where did your pain begin?)
2.
3.
4.
5.
6.
7.
8.
9.
b. What were you doing when the pain began? What brings the pain on?
c. Does the pain begin suddenly or gradually?
How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
Was your pain continuous or does it come and go? Quantity
a. How many times do you have pain per day/week/month? (how often?)
b. How long does it last for each episode (every time)?
Now, if compare with the onset, is the pain getting worse or better? P
Does the pain move around or stay in one place? Radiation
Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
Does anything relieve the pain? (Does anything make the pain better?) Alleviation
2 Cough:
1. Did the chest pain occur at the same time with cough? When did your cough
begin?
2.Is the dry cough or productive cough?( are you congested )( or cough with the
phlegm)? Productive cough
Can you estimate the amount of your phlegm?
What color is the phlegm?
Is there blood in the phlegm?
Does the phlegm have a strong smell? Do you notice a strong odor?
3. Association:
General
1.Did you have any fever?
Res.Sys.
2. Did you feel SOB?
3.Did you have any wheezing?
Digestive :
4.Did you have any nausea or vomit?
5.Did you have heart burn (or GE reflux disorder)?
4. Sick contact
Have you had closest contact with any one who having the same Problem?
PAM
6. Have you had chest pain and cough before?
7. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
8. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
9. Do you take any medication?
10. Have you had a tuberculin test? Or PPD test? Whats the result?
HsitUGDWS
1. Have you ever been hospitalized before? H
A. History taking. Hello Maam, Ms. Rice. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can I help you today? Can you tell me more something about your problem?
( Patient dont let Dr examine) I know you are in pain. But I need to examine you and find
out the source of your pain.
You need to have an exact treatment.
1LiqorAAA OI LQL Qn RAAA
1. When did your pain begin (start)? Onset
a. Where did you first feel the pain? (where did your pain begin?)
b. What were you doing when the pain began? What brings the pain on?
c. Does the pain begin suddenly or gradually?
2. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
3. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
4. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
a. Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
5. Was your pain continuous or does it come and go? Quantity
a. How often do you have stomachache? How many times do you have pain
per day/week/month?
b. How long does it last for each episode (every time)?
6. Now, if compare with the onset, is the pain getting worse or better? P
7. Does the pain move around or stay in one place? Radiation
8. Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
9. Does anything relieve the pain? (Does anything make the pain better?)
Alleviation
Did the pain relate to eating? Can you relate it to any type of food (Fat eating?) Is
your pain related to any type of food?
Did the pain relate to posture?
Have you had jaundice?
Have you had any change color of your eyes?
Association:
General
1.Did you have any fever?
Res.Sys.
1. Did you feel SOB?
2. Did you have any wheezing?
3. Did you have any chest pain?
Digestive :
1. Did you have any nausea or vomit?
2. Did you have heart burn (or GE reflux disorder)?
Sick contact
Have you had closest contact with any one who having the same Problem?
PAM:
Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)
*Challenging questions patient? My husband is a nurse, he said that: I need to have
an operation?
1. I know you could be feeling anxious and scared. Most patients feel nervous when
they hear that surgery might be needed.
2. There are many conditions which could be causing your problem.
3. I cannot rule out the possibility that you may need to be treated with surgery.
4. After I examine you and run some tests I am sure we will know the correct treatment
for you.
5.
5. Please try not to worry because the staff and I are here to give you the best possible
care.
B.Exam component:
Pulmonary:A
CV: A2
Abd exam: IAPa( Murphy, Guading, CVA tenderness)Pe(liver)
What you say when you do PE:
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. Let me take a look at your back.
3. Can you say 99 for me, please.
4. Im going to tap on your back to check your lungs. Is that ok with you?
5. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
Lying down
1. Im going to examine your heart. Let me open your gown to uncover your chest.
2. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Do you feel any pain when I press in or when I let go? Which hurts more? (Rebound
tenderness).
7. I need to press in on your stomach area. Please take a deep breath and let me know If
it hurts. ( Murphy sign)
8. Now I need to tap on your stomach.(liver)
Special tests:
9. Please turn over to your left side.
Im going to tap on your back now. let me know if it hurts. ( CVA tenderness).
C. Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having inflammation or stone in your gallbladder.
3. However, there are also other conditions which could be causing your stomachache.
Alleviation
Does the pain relate to eating a meal? How long after eating does the pain
occur? Does food relieve the pain?
.Does the pain usually occur in the day time or at night?
.Association:
a. (Does your pain relate to exertion? SOB? Sweating?)
b. Do you have nausea or vomiting? Have you ever been nauseated or vomited
? Is there blood in your vomitus?
c. Have you had any change in your bowel movement?
Do you have diarrhea or constipation?
Patient note
History
HPI:
ROS:
PMH:
Allergies:
Medications:
PSH:
SH:
FH:
Physical Examination
VS
Chest
Heart
ABD:
Differential Diagnosis
Diagnostic workup
6.
7.
8.
9.
Alleviation
Association:
Digestion
1.Do you have nausea or vomiting?
2. Have you had any change in your bowel movement?
Do you have diarrhea or constipation?
Uro:
1. Have you had any change in your urination? U(frequency, burning)
Have you had burning during urination?
Have you noticed an increase in the frequency of urination ?
2.. Do you have any fever?
PAM:Now I need to ask you a few questions about your health in the past. Is that OK
with you?
1. Have you had the stomachache before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
H(sit)UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
FOSxS:
FH:
1. Does anyone in your family have stomachache like you?
2. Does anyone in your family have any other medical problem? Are your parents alive?
Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period?
4. Was your cycle regular or irregular?
5. How many days are there between your periods? How many days are in your period
cycle?
6. How long does each period last?
7. How many pads or tampons did you use on those days? Per day?
8. Are you sexually active? Sx
9. When was your last sexual contact?
10. Have you ever had a vaginal discharge?
7. I need to press in on your stomach area. Please take a deep breath and let me know If
it hurts. ( Murphy sign)
8. When I press in here(LLQ) , Do you feel pain in right side(RLQ)? Rovsing sign
9. Now I need to tap on your stomach.
Special tests:
1. I need to uncover your right leg. Im going to bend it. Tell me if it hurts. (Obturator
sign).
2. Please turn over to your left side.
Im going to tap on your back now. let me know if it hurts. ( CVA tenderness).
3. I need to lift your right leg and pull it back. Tell me if this is painful. (Psoas sign)
Exts
. I need to find any changes in your legs.
C.Counseling:
1. Well, maam, Based on your information and the findings from your physical
examination.
2. I think you might be having inflammation of your womb.
3. However, there are also other conditions which could be causing your abdominal
pain.
Such as pregnancy, infection of( appendix) gut, abortion, etc
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
With your permission I need to run pregnancy tests
and You need to be have a pelvic and rectal examination.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
1. To protect your health.
. You should practice safe sex, and tell your sexual partners to always
use a condom
.You should have a paps smear regularly.
Is that alright? Do you have any more questions?
Goodbye, maam. See you later.
Patient note
History
HPI:
ROS:OB/GYN
PMH:
Allergies:
Medications:
PSH:
SH:
FH:
Physical Examination
VS
Chest
Heart
ABD:
Differential Diagnosis
Diagnostic workup
Alleviation
Loss weight
3. Did you lose your weight?
4. How many pounds did you lose? Over what period of time did you lose this
weight?(How much weight did you lose? How long have you been losing weight?)
Association
Digestive
5. Do you notice any pain when you eat? (Did the pain relate to eating
6. Is this pain usually at night or in the day time?
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
GAD.
HEENT
Eyes:icteric
Neck: Pa lymph node &axillary
Pulmonary:Pa A
CV: A
Abd exam:I A,Pa,Pe
Skin: jaundice
Exts: Edema, Cyanosis, Phlebitis
Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes:icteric Id like to examine your eyes now.
lymph node Let me press lightly on your neck and armpits
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. Let me take a look at your back.
3. Can you say 99 for me, please.
4. Im going to tap on your back to check your lungs. Is that ok with you?
5. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1.I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.
2. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.
Special tests:
1.Please turn over to your left side.
Im going to take a look & press on your back now. let me know if it hurts. ( CVA
tenderness).
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did
you lose or gain? Over what period of time did it happen?) How long have you
been losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FoSxS
FH:
1. Does anyone in your family have shortness of breath and cough?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
Eye: PERLA, FO
Neck: JVD ,carotid bruits
Pulmonary: A
CV: A2, PMI,
Abd exam: Pe liver Span
Ill be in a better position to tell you your diagnosis and treatment options.
2. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with the low salt and low fat.
3. Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.
BM
Have you had any change in your bowel movement? G
Sleep
Have you had any change in your sleep patterns? S
Diet-Exercise-Weight
4. Are you on a diet?
5. How is your appetite?
6. Do you exercise regularly?
7. Have you had any change in your weight recently?
PAM
1. Have you had any other medical problems? Example: Stroke, , diabetes.
When did you last have your cholesterol level checked?
What was the result of your last cholesterol test?)
2. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
3. Do you take any another medication?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
FOSxS.
FH:
1. Does anyone in your family have high blood pressure?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
*Challenging question:
5.when does the food get stuck? Does the food get stuck when you begin or end of
swallow?
6.Where does the food get stuck?
7.How severe are your symptoms? are you able to eat a meal?
Association: Beside difficulty swallowing do you have any symptoms?
1.Is there any pain when you swallow?
2.Is there nausea or vomiting? (contain, color, odor, blood in it)
3.Do you have fever or chill?
4.Have you had weight loss or fatigue?
5.Have you had foul breath?
6. Have you had a hoarse voice?
Thyroid
7.Have you had swelling of the neck?
8.Do you feel hot or cold and others dont?
Scleroderma)
9.Have you noticed any change in your skin or nails?
Alleviation: Does any thing make your swallowing better?
PAM:
1.Have you had difficulty swallowing before?
2.Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes
Have you ever swallowed any type of corrosive liquid? acid, base, soap(detergent)
3.Are you allergic to anything? (Plants, food, medication..). Do you have any allergies?
4.Do you take any medication?
HSitUGWD
2. Have you ever been hospitalized before? H
3. Have you ever had surgery? S
4. Have you had any trauma or injuries? I &T
5. Have you had any change in your urination? U
6. Have you had any change in your bowel movement? G
7. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
8. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
9. Have you had any change in your sleep patterns? S
FOSx S
FH:
1. Does anyone in your family have difficulty swallowing?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
*Challenging Question:
2. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
3. I need to listen to your neck. ( the bruits of carotid arteries or thyroid gland).
4. Let me touch lightly on your armpits
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down : Could you lie back on the table.
2. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
3. Im going to examine your heart. Let me open your gown to uncover your chest.
4. I need to listen to your heart.
Abdominal exam.
6. I need to examine your belly now Let me uncover your stomach.
7. Im going to take a look at your stomach area.
8. Im going to listen to your belly.
9. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
I need to press a little more deeply now.
Exts:
I need to find any changes in your legs. ( Edema, Cyanosis)
Skin,nail ( Scleroderma)
I need to check your skin, and your hair
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having a narrowing of your esophagus.
3. However, there are also other conditions which could be causing your difficulty
swallowing.
Such as spasmodic disorder or a tumor in your esophagus, etc.
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
6. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with low fat, low salt.
2. Is that alright? Do you have any questions?
Goodbye, Sir. See you later.
16.CASE 18:Diarrhea
A. History taking. Hello Sir, Mr. Golden. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
1.Can you tell me more something about your diarrhea?
2.When did your diarrhea begin? O
2. How many times do you have bowel movements every day? Qn
3.Is it large amount of each time? (What is the amount of your stool)? Qn
Does anyone in your family have any other serious medical problem? DM, HIV,
IBDAre your parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
6. Are you sexually active?
7. How many sexual partners do you have?
8. Are they male or female or both?
9. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
10. Have you ever been tested for sexually transmitted diseases or example HIV ?
SH:
5. Whats your job?
6. Do you have any stress in your life?
7. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
8. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
9. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
10. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
Eyes
Oral : ulcer,thrush
Pulmonary: A
CV: A
Abd exam: I A PaPe
Joints
Skin: rashes
c.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having bowel inflammation.(inflammation of the gut)
3. However, there are also other conditions which could be causing your diarrhea.
Such as mal-absorption, bowel infection, food poisoning, etc .
11. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
You need to be have a rectal examination
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options
6. To protect your health.
You should have a healthy diet, food with low fat and dont eat out
at restaurants or at parties.
Association
Digestive:
12. Do you have nausea or vomiting? blood vomit?
13. Did you have a stomachache?
Lung
15.Have you had lung problems before?
Bile duct
16. Did your eye and skin become yellow? Did you have itchy skin?
General
1. Do you have pain anywhere in your body? joint? How do you treat it?
2. Do you have any fever?
Sick contact
1. Have you had close contact with someone who has the same problem like
you?
2. Have you traveled recently?
Affect:
1. Have you ever had dizziness?
2. Have you felt unsteady when you walk?
3. Have you ever loss of consciousness?
PAM
1. What does your blood pressure normally run?
2. Have you ever had bleeding like this before? Dark stool?
3. Did you have any other medical problem? Liver didease, PUD
4. Are you allergic to any medication?
5. Do you take any other medication, especially (NSAIDs?) example killer pain,
ibuprofen?
HsitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
14.
Please try not to worry because the staff and I are here to give you the best
possible care.
B.Exam component:
Blood loss: eyes, under tongue. Palms, JVD
CV: A
Pulmonary: A
Abd exam: I A Pa(Murphy) Pe
Exts: Edema ,clubbing, cyanosis
What you say when you do PE
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes, Mouth ,Palm
Id like to examine your eyes, mouth, palms to look for if you have had anemia
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
2. Im going to examine your heart. Let me open your gown to uncover your chest.
3. I need to listen to your heart
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.(liver)
7. Do you feel any pain when I press in or when I let go? Which hurts more? (Rebound
tenderness).
Exts:
I need to find any changes in your legs.
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having hemorrhaging due to a stomach ulcer.
3. However, there are also other conditions which could be causing your black stool.
Such as medication, inflammation of bile-duct or liver disease, etc.
3. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
You need to be put a tube in your mouth.
You need to be have a rectal exam
14. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
15. Have you had any change in your sleep patterns? S
FOSx S
FH:
1. Does any women in your family have vaginal discharge?
2. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period
*Challenging question:
Do you think Im going to lose my baby?
1.This is good question
1.There are many conditions which could be causing your vaginal bleeding.
2. Losing the baby- what we call an abortion, is one of them.(causes)
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and
imaging studies.
5. Once I get the results of these tests.
6. Ill know what is causing of your bleeding.
7.Please try not to worry because the staff and I are here to give you the best possible
care.
B.Exam component:
Anemia: eyes, under tongue. Palms
ENT:nose, gum
Neck exam: Thyroid gland,DTR
Pulmonary: A
CV: A
Abd exam:A PaPe,Rebound
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes:
Visual fields Please, follow my fingers without moving your head (4 directions)
EOM: Please, follow my fingers without moving your head (8 shape)
Neck
1. I need to check your neck area.
2. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
3. I need to check your skin, and your hair
4. Please hold on your hands like this and close your eyes. ( check tremors).
DTRS
1. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
2. I need to tap on your legs. (patellar, Archilles)
Pulmonary Exam.
Posterior Chest.
11. I m going to examine your lungs. May I untie your gown
12. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.
13. I need to listen to your heart
Abdominal exam.
14. I need to examine your belly now Let me uncover your stomach.
15. Im going to take a look at your stomach area.
16.
17.
18.
19.
20.
Sexual active May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many partners do you have?
3. Do you use any contraceptive? Do your partners always use a condom or only
sometimes?
4. When was your last sexual contact ?
5. Have you had any Sexually Transmitted Diseases or pelvis inflammation?
6. Have you ever had any nipple discharge?
Association
Abd pain
1 Have you had any stomachache?
Depression-anxiety-stress
1. Hows about your mood? Have you had a bad mood?
2. Do you have any stress in your family or at school?
3. Do you have any anxiety or palpitation?
Thyroid disorder
5. Have you had any swelling or mass in your neck?
6. Do you feel hot or cold when others dont? Do you feel hot or cold when other people
are feeling normal?
7. Have you noticed any change in your voice recently?
8. Have you had any changes in your bowl movement? Constipation?
Pituitary gland
1.Do you have headaches very often?
5. Do you notice any changes in your eyes? Visual Changes?
PAM
1. Have you ever missed your periods before?
2. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
H(sit)UGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FH:
1. Does any women in your family have miss their periods like you?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
* Challenging question:
Do I have pregnancy or menopause?
6. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
7. I need to check your skin, and your hair
8. Please hold on your hands like this and close your eyes. ( check tremors).
DTRS
3. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
4. I need to tap on your legs. (patellar, Archilles)
Pulmonary Exam.
Posterior Chest.
21. I m going to examine your lungs. May I untie your gown
22. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.
2. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.(liver)
Exts:
I need to find any changes in your legs.
C.Counseling:
1. Well, maam, Based on your information and the findings from your physical
examination.
2. I think you might be having anxiety disorder.
3. However, there are also other conditions which could be causing the delay your
period.
Such as pregnancy, abnormality of your thyroid gland, or depression etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
With your permission I need to run pregnancy tests and
You need to be have a pelvic and breast examination.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
6. To protect your health.
You shouldnt smoke or use alcohol.
You should practice safe sex, and tell your sexual partners to always
use a condom
Is that alright? Do you have any more questions?
Goodbye, maam. See you later.
5. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
6. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
7. Have you had any change in your sleep patterns? S
FOSxS
1. Does anyone in your family have dark urine?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. Do you notice any change in your period
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active? Have you had any change in your sexual activity recently?
2. How many sexual partners do you have?
3. Are they male or female or both?
4. Do you use any contraceptives?
5. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
*Challenging Question:
Ill be in a better position to tell you your diagnosis and treatment options.
1. To protect your health.
You should quit smoking.
You should drink a lot of water every day.
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.
1.Has your child had close contact with any one having the same problems? (Does
any one in her family or her daycare or babysitter have a similar problem? )
2.Did your child travel anywhere recently?
3.Did your child eat out at a party or restaurant recently?
FH
2. Does any one in your family have a similar problem? Does any one in your family
have fever and shaking like her?
3. Does any one in your family have other medical problem?
HsitUGWDS
1. Has your child ever been hospitalized before? H
2. Has your child ever had surgery? S
3. Has your child had any trauma or injuries? I &T
4. Whats her appetite been like? D (Is there any kind of special diet that your child
are following?)
Did you breast-feed your child? Is your childs formula fortified with iron?
Have you changed her food recently?
5. Has your child had any change in her weight recently? W (How many pounds did
your child lose or gain? Over what period of time did it happen?) How long has
your child been losing or gaining your weight?
6. 22.Has your child had any change in her sleep patterns? S
Pregnancy: How about your pregnancy
1. Did you smoke, drink or use drugs during your pregnancy?
2. Did your child have any complications during your pregnancy, delivery or after
delivery?
. Was it a normal delivery or a C-section?
3. When did your child have her first bowel movement?
Development:Tell me some things about your child s development?
When did your child first smile? When did your child first sit up? when did your child
start talking? when did your
child start walking? When did your child start putting
things in his mouth?
Children >3-4 years old:
When did your child learn to dress himself? When did your child learn to tie the
shoes?
When did your child start using short sentences?
Vaccination:
4. Has your child had all the necessary vaccination? Did your child have vaccine
shot enough?
Pediatrician:
1.Do your child have a doctor that takes care of her on a regular basis? His name? His
address?
2.When was her last check up?
C.Counseling:
1.Based on your information about your child.
She has had a fever for about 3 days and a seizure, and diarrhea
She has developed normally, and she has had all her vaccinations
2. I think your child might be having viral upper respiratory infection and seizure
from having a high fever( fertile fever)
3. However, there are also other conditions which could be causing your childs
problem.
Such as food poisoning, intestinal (gut) or urinary tract infection.
1. To have the exact diagnosis. I need to examine your child and run some blood tests,
urine tests,
and imaging studies.
.
Will it be convenient for you to bring your child to the hospital? Is that OK with you?
Challenging Question:
1. Doctor, I cant go to your hospital right now because I have two children, nobody
will take care for my older child while I am gone, also I dont have any car to take
Ann to your hospital?
Patient note
History
HPI:
ROS:
PMH:
Allergies:
Medications:
PSH:
Birth history:
Dietary history:
Immunization history :
Developmenhistory:
Physical Examination
none
Differential Diagnosis
Diagnostic workup
23.Case 27:Enuresis :Father come your office alone and said that
My son has problem in his life.
A. History taking.
Hello Mr. Jones , Can you tell me some more details about your sons problem? Nice to meet
you! (
1.
(my son wets his bed at night)
2. When did it begin? (How long ago did it begin? )3m.
Bed Wetting.
3. How often does he wet his bed? Does your son wet his bed every night or every 2 or
3 days?
4. How many times does he wet his bed every night?
5. Can you estimate the quantity of urine when he wets his bed? (Is the bed usually
pretty wet?)
6. Does he wet his bed at nap time?( Is there any particular time when he wets his bed?)
( early in the night or more toward morning?)
Urine daily
a. When did your child first smile? When did your child first sit up? when did
your child start talking? when did your child start walking? When did your
child start putting things in his mouth?
b. When did your child learn to dress himself? When did your child learn to tie
the shoes?
c. When did your child start using short sentences?
d. Would you describe him as playful, social, shy, or quiet?
e. Does he do well at his school?
f. Do you think he is worried about anything? Does he ever feel lonely?
Vaccination:
Has your child had all the necessary vaccination? Did your child have vaccine
shot enough?
Pediatrician:
1.Do your child have a doctor that takes care of his on a regular basis? His name? His
address?
2.When was his last check up (with Dr)??
Family:
1.Did any one in your family wet the bed when he( they) were young?
2. Does any one in your family have other medical problem? DM, sickle cell
Causing
What do you think is causing your son to wet the bed?
C Counseling:
1. Based on your information about your son (Let me review what you have told me )
.
I know that he has been wetting the bed for about 3 months, 3 times
per weeks, only at night.
He developed very normally.
2. I think that his bedwetting might be having a common problem that usually occurs
in
male children.
3. However, there are also other conditions which could be causing his problem.
Such as urinary tract infection, diabetes.
4. I cant say for sure until I didnt examine him personally. You need to
bring him to my office.
After examining him I need to run some blood tests, urine tests, and imaging studies
Counseling:
Until you bring him in for an examination you can try some of these helpful
suggestions:
1.Monitor your sons fluid intake during the day.
2.Limit the amount of fluid intake before going to bed.
3.Encourage your son urinate before going to bed.
4.Set an alarm clock and awake him up every 2-3 hour to void urine.
5.Attach a bed-wetting alarm
to your sons underwear. His urine
will trigger off the alarm ringing.
6.Change his pajamas and the bed sheet if he wets them at night.
7.Motivate your son and reward him when he is successful
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later .
Patitient note
History
HPI:
ROS:
PMH:
Allergies:
Medications:
PSH:
Birth history:
Dietary history:
Immunization history :
Developmenhistory:
Physical Examination
none
Differential Diagnosis
Diagnostic workup
24.CASE 4:Insomnia
A. History taking. Hello maam, Miss. Dura. Im Dr. Le. Nice to meet you! (First I need to
cover you with the sheet. Is that comfortable)
How can help you today?
1. Can you tell me more details about your problem?
2. When did your problem begin (start)? Onset (How long have you been having
problems with sleep?)
3.Do you have problems falling asleep? Yes
a. When do you usually go to bed?
b. How much time does it take you to fall asleep? What average length of time
between go to bed and falling asleep?
c. What do you do before going to bed? Exercise in the late evening? Drink alcohol?
Smoke after dinner? Drink coffee?
d. Do you watch TV while lying in bed?
4.Do you have problems staying asleep?
a. Do you wake up several times during the night?
b. What did you do during that time?
c. Do you wake up often to urinate?
d. Do you experience any problem with breathing, coughing, taking medication?
5. Do you have problems with waking in your sleep?
6.Have you or any of your family members noticed that your sleep is restless or that you
move around a lot in your sleep?
7.Beside the sleep problem do you have other problems?
a. Did you have pain anywhere in your body?
b. Have you had any change in your bowel movements?
c. Have you had any change in your urination?
Anxiety
d. Do you have feelings of fears or are you anxious all the time?
PTSD
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
5. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
6. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
Exam component:
Neck: Pa thyroid gland, Muscle strength, DTRs
Pulmonary: A
CV: A
Abd: light,deep presss
What you say when you do PE
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is
that ok with you?
Neck
9. I need to check your neck area.
10. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
11. I need to check your skin, and your hair
12. Please hold on your hands like this and close your eyes. ( check tremors
Musle testing: (M)Now Im going to check the strength of your muscle now.
MRS
1. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
2. Please, do this(elbow flexion). Pull in. Pull out.
3. Please, make the fists. Dont let me open them. ( Wrists).
4. Please, Spread your fingers apart. (Hands).
5. Please, Push your thigh up. Push your thigh down.( Thigh).
6. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
7. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
5. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
6. I need to tap on your legs. (patellar, Archilles
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
1. Im going to examine your heart. Let me open your gown to uncover your chest.\
5. Did you hear a racing of your heart? Did you have sweating or tremor of your
hands?
Depression :You look sad do you know the reason?
1. Hows about your mood?
2. Are you able to concentrate on your work very well?
3. Do you feel lonely?(Do you have feelings of being emotionally distant and lonely?)
4. Do you have good family support?
5. Are you feeling guilty about anything?
6. Do you ever think about suicide? Have you ever had a suicide idea or you got it over
one time?
How do you think you would kill yourself?
Do you have a gun and pills at home?
Manic episode-delusion-hallucination:
1???.Have you ever had an intense enthusiasm( excitement)??????
1.Do you ever see or hear things when others cant see or hear them?
2.Do you feel as if other people are trying to harm or control you?
Weight & Diet
1. Have you noticed any changes in your weight?
2. Whats your appetite been like?
3. Do you like to eat more than you usually do?
Hyper-Hypothyroidism
1. Do you have any swellings or lump(masses) on the neck?
2. Have you noticed any change in your skin and hair?
3. Do you feel cold or hot when other dont?
4. Have you noticed any change in your voice recently?
General
27.Do you have a fever?
28.Have you had any changes in your urination?
29.Have you had any changes in your bowel movements?
30.Woul you like to meet with a counselor to help you with your problems?
31.Would you like to join a support group? Do you think joining a support group might
help you?
PAM
4. Have you ever been had fatigue before?
5. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
6. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
7. Do you take any medication?
HSitUGDWS
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
FoSSx
1. Does anyone in your family have fatigue
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
O &G:
1. When was your first period?
Id like to examine your eyes, mouth, palms to look for if you have had anemia
Neck
13. I need to check your neck area.
14. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
15. I need to check your skin, and your hair
16. Please hold on your hands like this and close your eyes. ( check tremors).
Reflexes: (R)
1. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
2. I need to tap on your legs. (patellar, Archilles)
Pulmonary Exam.
Posterior Chest.
3. I m going to examine your lungs. May I untie your gown
4. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
2. Im going to examine your heart. Let me open your gown to uncover your chest.\
3. I need to listen to your heart.
C.Counseling:
1. Based on your information and the findings from your physical examination.
2 I think you might be having depression.
3. However, there are also other conditions which could be causing your problem.
Such as anemia, thyroid disorder, anxiety, stresses from your life etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once we get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
8. To protect your health.
You shouldnt smoke or use alcohol, caffeine.
I d like to transfer you to psychiatric counseling.
Would you be willing to talk to a counselor or go to a support group?
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.
Anxiety-stress
19. Do you have any stress in your life?
Do you feel anxious all the time? (Do you have any anxiety or palpitation?)
Depression1. Hows about your mood?
2. Are you feeling guilty about anything?
3. Do you ever think about suicide?Have you ever had a suicide idea? Have you
ever thought about hurting yourself?
If you thought about suicide how do you think you would kill
yourself? How do you kill yourself?
Do you have guns and pills at home
1. Have you had any changes in your urination?
2. Have you had any changes in your bowel movements?
PAM
a. Have you ever been had physical abuse
a. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
b. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
c. Do you take any medication?
HSitUGDWS
a. Have you ever been hospitalized before? H
b. Have you ever had surgery? S
c. Have you had any trauma or injuries? I &T
d. Have you had any changes in your urination?
e. Have you had any changes in your bowel movements?
f. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
g. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did
it happen?) How long have you been
losing or gaining your weight?
h. Have you had any change in your sleep patterns? S
FH:
a. Does anyone in your family have any other major medical problem? Are your parents
alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
a. Are you sexually active?
b. How many sexual partners do you have?
c. Are they male or female or both?
d. Do you use any contraceptives?
e. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
20. Whats your job?
21. Do you have any stress in your life?
22. Do you smoke? How much, How often? (how many packs a day? How long
have you smoked?)
23. Do you use alcohol? (What do you drink? How much do you drink per week?
How long have you drunk?)
24. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)
B. Exam component:
Right arm compare both arm in term of I , Pa,
Muscle strength.
sensation, DTRs,
pulses.
Other Injuries
Pulmonary: A
CV: A
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Arms
1. Im going to examine your arms. I need to untie your gown and uncover your arms
2. I d like to take a look first.
3. Im going to touch your arms. Tell me if it hurts
Muscle Strength.
Now Im going to check the strength of your muscle now.
1. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
2. Please, do this(elbow flexion). Pull in. Pull out.
3. Please, make the fists. Dont let me open them. ( Wrists).
4. Please, Spread your fingers apart. (Hands).
Sensation
Im going to touch your arm lightly. Please close your eyes. Do you feel this .Is it the
same
Pulse:
I need to check the pulse in your arms
DTRs
Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
Pulmonary: I need to listen to your lungs. Please, take a deep breath for me.
CV : Could you lie back on the table, I need to listen to your heart
Exts
I need to look for another injuries
C.Counseling:
1. Well, maam, Based on your information and the findings from your physical
examination.
2. I think you might be having the bruises from spouse abuse.
3. However, there are also other conditions which could be causing your problem.
Such as sexual abuse, or depression, or a fracture of your bones, etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
CV: A
Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
HEENT
Eyes
a. Id like to touch your face .(find a abnormalities of your salivary gland)
b. I need to check the inside of your mouth and your throat, your teeth.
c. Id like to examine your eyes now. I need to dim the light in this room. Im going
to shine this light in your eyes. Can you pick a point on the wall and look at it.
Neck
a. I need to check your neck area.
b. Let me press lightly on your neck. I need you to swallow. (Do you need any water)
Abdominal exam.
10. I need to examine your belly now Let me uncover your stomach.
11. Im going to take a look at your stomach area.
12. Im going to listen to your belly.
13. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
14. I need to press a little more deeply now.
15. Now I need to tap on your stomach.
Special tests:
16. Please turn over to your left side.
Im going to tap on your back now. let me know if it hurts. ( CVA tenderness).
Exts
1.I need to check your skin, and your hair
2.I need to check for fluid retention in your legs.
Pulmonary Exam.
Posterior Chest.
1. I m going to examine your lungs. May I untie your gown
2. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1. I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
1.Im going to examine your heart. Let me open your gown to uncover your chest.
I need to listen to your heart
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might have anorexia Self- induced vomiting. (anorexia nervosa, binge
eating, purging type)
3. However, there are also other conditions which could be causing your problem.
Such as: food, medication, obstruction of the gut, or pregnancy, etc.( bulimia
nervosa)
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
With your permission I need to run pregnancy tests
and You need to be have a pelvic, and rectal examination.
3. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
5. Have you ever been tested for PPD or tuberculosis? Did you ever test positive for
PPD or tuberculosis?
6. Have you ever had close contact with someone that had TB?
HSitUGWD
1. Have you ever been hospitalized before? H
2. Have you ever had surgery? S
3. Have you had any trauma or injuries? I &T
4. Have you had any change in your urination? U
5. Have you had any change in your bowel movement? G
6. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
7. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
8. Have you had any change in your sleep patterns? S
FOSxS
1. Does anyone in your family have night sweat like you?
2. Does anyone in your family have any other serious medical problem? cancer
?thyroid problem?Are your parents alive? Good health?
O &G:
1. When was your first period?
2. When was your last menstrual period?
3. 40.Do you notice any change in your period
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
4. Are you sexually active?
5. How many sexual partners do you have?
6. Are they male or female or both?
7. Do you use any contraceptives?
8. Does your sexual partners always use a condom or only sometimes? (Do you use a
condom consistency or inconsistency?)
SH:
a. Whats your job?
b. Do you have any stress in your life?
c. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
d. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
e. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
*challenging question:
1.To protect my self, do I need to give up my job?
1. This is good question.
2. There are many conditions which could be causing your problem.
6. Please try not to worry because the staff and I are here to give you the best possible
care.
8. Please try not to worry because the staff and I are here to give you the best possible
care.
B. Exam component:
HEENT:
Eyes=Lidlag, exophthalmos
Oral cavity=ulcer, thrush
Neck exam: I, Pa=
Thyromegaly? Masses.
Lymphnode
Pulmonary: A
CV: A
Abd exam: IAPaPe
Ext=tremor, edema, muscle strength, DTRs
Skin= Sweating, nodular, petechia, splinter hemorrhages, oslers nodes, Janeway lesion
MRS
Please, Hold out your arms like this. Push up. Push down ( Shoulders)
Please, do this(elbow flexion). Pull in. Pull out.
Please, make the fists. Dont let me open them. ( Wrists).
Please, Spread your fingers apart. (Hands).
Please, Push your thigh up. Push your thigh down.( Thigh).
Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
a. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
b. I need to tap on your legs. (patellar, Archilles)
c. Now I need to tickle your feet lightly. (Babinski)
Skin.
I need to check your skin
C.Counseling:
1. Based on your information and the findings from your physical examination.
2 I think you might be having panic disorder.
3. However, there are also other conditions which could be causing your problem.
Such as medication, thyroid disorder, stresses from your life or chronic infection
(TB),(or malignant lesion), etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
a.
b.
c.
d.
e.
f.
g.
Alleviation
ASSOCIATION
Digestive
3. How is your appetite? Do you feel hungry more often than you used to?
4. Do you often feel thirsty?
5. Do you have any nausea or vomit?
6. Do you have any change in your bowel movement?
EYE
7. Have you had any change in your vision?
Respiratory
9 Did you feel a shortness of breath?
B. Exam component:
Eyes: PERLA, FO
Chest: IPaPeA
CV: Heart: A
Abd: I A Pa Pe
Lower Extremities:
Pulses both legs and arms
sensation in both legs
Motor
DTRs, Babinskis sign in both legs.
color change & hair loss& injuries
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eyes:
1. Id like to examine your eyes now. I need to dim the light in this room. Im going to
shine this light in your eyes. Can you look at the clock on the wall. (Can you pick a point on
the wall and look at it.). Ill examine the back of your eyes
. Pulmonary Exam.
Posterior Chest.
5. I m going to examine your lungs. May I untie your gown
6. Let me take a look at your back.
7. Can you say 99 for me, please.
8. Im going to tap on your back to check your lungs. Is that ok with you?
9. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
3. I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
4. Im going to examine your heart. Let me open your gown to uncover your chest.
5. I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. Im going to take a look at your stomach area.
3. Im going to listen to your belly.
4. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
5. I need to press a little more deeply now.
6. Now I need to tap on your stomach.
Lower Extremities:
Active and Muscle Strength.
1. Now Im going to check the strength of your muscle now.
2. Please, Push your thigh up. Push your thigh down.( Thigh).
3. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
7. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Sensation
1 Im going to touch your legs lightly. Please close your eyes. Do you feel this .Is it the
same
2 This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)
Diagnosis:
1.Transient ischemic attack.
2.Disorder of cardiac rhythm or coronary artery disease
3.Thrombotic or embolic stroke
4. Seizure disorder.
5.Carotid dissection
6.Hyper or hypoglycemia.
A.History taking:
Hello Mr.White. Im Dr. Truong. Nice to meet you! (First I need to cover you with the sheet.
Is that comfortable)
1. How can I help you today?
2. Please, tell me more details about your problems?
3. You said you had weakness in your arm yesterday. How long did it last?
4. Before you had weakness your arm did you have any symptoms?
5. After the weakness did your arm return to normal?
6. After the attack were you conscious or unconscious?
Mini-mental Status
1. Id like to ask you some questions to test your orientation.
Can you tell me your name and age?
Where are you now?
Whats the date today?
2. Id like to check your memory.
This is a chair ,a bed, and a pen
Now can you repeat for me the names of the three objects.
What did you have for lunch yesterday?
Who was the first president of the United States?
3. Id like to check your concentration.
Please take 7 away from 100 and tell me what number you get.
Then keeping taking 7 away until I tell you to stop.
4. Id like to test your judgment
1. What would you do if you saw a fire coming out from a paper basket?
ASSOSIATION
Heent-Neuro
2. Do you have headache very often?
3. Do you feel dizzy?
4. Have you ever fainted? ( passed out ?) ?
5. Have you had a seizure before?
6. Have you had any change in your vision?
7. Have you had any discharge from your eyes , ears, nose ?
8. Did you feel numbness or loss of sensation any where in your body?
9. Could you walk?falling?
10. Did you have difficulty walking?
Cardio-vascular
1. Did you have any chest pain?
2. Did you hear a racing in your heart?
7. Did you feel SOB?
Digestive
1.Have you had any change in your bowel movement?
Urinary
2. Have you had any change in your urination?
PAM
8. Have you had weakness before?
9. Have you had any other medical problems? Example: high blood pressure, high
cholesterol, diabetes.
10. Are you allergic to anything? (Plants, food, medication..). Do you have any allergies?
11. .Do you take any medication?
12. .Have you ever had high blood pressure? DM? When did you last have your
cholesterol level checked?
What is your last cholesterol level?
How did you treat HTN,DM?
HsitUGDWS.
Have you ever been hospitalized before? H
Have you ever had surgery? S
Have you had any trauma or injuries? I &T
Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
5. Have you had any change in your weight recently? W (How many pounds did
you lose or gain? Over what period of time did it happen?) How long have you
been losing or gaining your weight?
6. Have you had any change in your sleep patterns? S
1.
2.
3.
4.
FoSxS.
FH:
1. Does anyone in your family have weakness like you?
2. Does anyone in your family have any other serious medical problem? Are your
parents alive? Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
1. Are you sexually active?
2. How many sexual partners do you have?
Are they male or female or both?
3. Do you use any contraceptives?
4. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per week? How long
have you drunk?)
CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke or
inject them)
*Challenging question:
Weber: Im going to put this tuning fork on your head . Tell me if it sounds the same
in both ears.
Rinne: Let me put the tuning fork behind your ears. Tell me when you cant hear any
longer.
Can you hear now
CN 5: Please clench your jaws.( muscle of mastication)
Im going to touch your face lightly. Please close your eyes. Do you feel this
.Is it the same?(sensation)
CN 7 : Please lift your eyebrows.
Please smile and show me your teeth.
CN 11: Now turn your head and press it against my hands.
Please shrug your shoulders.
Neck
1. I need to listen to your neck. ( the bruits of carotid arteries or thyroid gland).
Pulmonary Exam. I need to listen to your lungs. Please, take a deep breath for me.
CV : Could you lie back on the table, I need to listen to your heart.
Abdominal exam.
1. I need to examine your belly now Let me uncover your stomach.
2. I need to press on your stomach. Tell me if you feel any pain or discomfort.
Musle testing: (M)Now Im going to check the strength of your muscle now.
MRS
1. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
2. Please, do this(elbow flexion). Pull in. Pull out.
3. Please, make the fists. Dont let me open them. ( Wrists).
4. Please, Spread your fingers apart. (Hands).
5. Please, Push your thigh up. Push your thigh down.( Thigh).
6. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
7. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
1. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
2. I need to tap on your legs. (patellar, Archilles)
3. Now I need to tickle your feet lightly. (Babinski).
Sensory(S): Now I need to check your sensations
10. This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)
Im done. Please open your eyes.
11. Im going to place this tuning fork on your body. Please close your eyes. Say yes if
you feel any vibration..
Im done. Please open your eyes.
3. This is up ( move up a toe).This is down (move down a toe). Please, close your eyes
and tell me up or down when I move your fingers or toes.( Position sense).
Cerebella:
Gait:
1. Now, please stand up (DR have to pull out the footstool .) Please walk to me.
2. Turn around. And go back, please, walk heel-toe-heel-toe. (Tadem gait.)
Romberg:
1. Please, stretch your arms out to your side and close your eyes.( Im in back behind
you. Im ready to help you if you feel unsteady
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having Problem of the blood vessels in your brain.
3. However, there are also other conditions which could be causing your problem.
Such as diseases of heart, or a seizure disorder, etc .
4. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
8. To protect your health.
You shouldnt smoke or use alcohol.
You should have a healthy diet, food with low fat, low salt.
You should exercise and check your blood pressure( if have HBP) and use
medication regularly.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.
16. Do you have any discharge from your eyes, ears , nose(Were there watery from your
eyes, ears, or nose???)
17. Do you have any bleeding from any where in your body?( Your nose, mouth,
coughing of blood )
18. Do you feel weakness any where in your body? Can you walk?
19. Did you feel numbness or tingling or loss of sensation anywhere in your body?
Neck
1. Can you move your neck naturally?
Chest
1.Did you have any chest pain?
2..Did you feel SOB?
Digestive
16.Did you have any changes in your BM or dark stool, blood stool?
17.Did you have nausea or vomiting?
Urinary
18.Have you had any changes in your urination? Have you had blood in urine or dark urine?
PAM
10. Have you had any major medical problems? Example: high blood pressure, high
cholesterol, diabetes.
11. Are you allergic to anything? (Plants, food, medication..). Do you have any
allergies?
4. Do you take any medication?
HsitUGDWS
13. Have you ever been hospitalized before? H
14. Have you ever had surgery? S
15. Have you had any trauma or injuries? I &T
16. Whats your appetite been like? D (Is there any kind of special diet that you are
following?)
17. Have you had any change in your weight recently? W (How many pounds did you
lose or gain? Over what period of time did it happen?) How long have you been
losing or gaining your weight?
Have you had any change in your sleep patterns? S
FoSxS
FH:
Does anyone in your family have any major medical problem? Are your parents alive?
Good health?
Sx: May I ask you some personal questions? Any thing you say will be kept
confidential, Is this OK with you? (Are you comfortable with this)
16. Are you sexually active?
17. How many sexual partners do you have?
18. Are they male or female or both?
19. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
SH:
11. Whats your job?
12. Do you have any stress in your life?
13. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
14. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
15. CAGE :
a. Have you ever felt a need to cut down on drinking?
b. Have you ever felt annoyed by criticism of your drinking?
c. Have you ever had guilty feeling about drinking?
d. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)
c.Counseling:
1. Based on your information and the findings from your physical examination.
You have had multiple bruises due to physical assault to your neck, chest.
You have a fever after the trauma. You have also had history of asthma.
2.I think you might be having multiple traumas in your head, neck and chest.
3.However, there are also other conditions which could be causing your fever.
Such as Inflammation or contusion of your lung, etc .
4.To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5.Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
Is that alright? Do you have any more questions?
Goodbye, Sir. See you later
MRS
8. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
9. Please, do this(elbow flexion). Pull in. Pull out.
10. Please, make the fists. Dont let me open them. ( Wrists).
11. Please, Spread your fingers apart. (Hands).
12. Please, Push your thigh up. Push your thigh down.( Thigh).
13. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
14. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
4. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
5. I need to tap on your legs. (patellar, Archilles)
6. Now I need to tickle your feet lightly. (Babinski).
Sensory(S): Now I need to check your sensations
12. This is sharp. This is dull. Please close your eyes. Tell me if you feel a sharp or dull
sensation Sharp & Dull)
Im done. Please open your eyes.
13. Im going to place this tuning fork on your body. Please close your eyes. Say yes if
you feel any vibration..
Im done. Please open your eyes.
3. This is up ( move up a toe).This is down (move down a toe). Please, close your eyes
and tell me up or down when I move your fingers or toes.( Position sense).
Cerebella:
Gait:
1. Now, please stand up (DR have to pull out the footstool .) Please walk to me.
2. Turn around. And go back, please, walk heel-toe-heel-toe. (Tadem gait.)
Romberg:
1. Please, stretch your arms out to your side and close your eyes.( Im in back behind
you. Im ready to help you if you feel unsteady
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having disease of the blood vessels in your brain.
3. However, there are also other conditions which could be causing your problem.
Such as vitamin B12 deficiency, depression, thyroid disorder, etc .
14. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
I need to obtain history direction from your family members
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
20. To protect your health.
I need to evaluate home safety and supervision.
Iwill find community resources that help you at home
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.
1.
2.
3.
4.
5. Does your sexual partners always use a condom or only sometimes? (Do you
use a condom consistency or inconsistency?)
SH:
1. Whats your job?
2. Do you have any stress in your life?
3. Do you smoke? How much, How often? (how many packs a day? How long have
you smoked?)
4. Do you use alcohol? (What do you drink? How much do you drink per day/week?
How long have you drunk?)
5. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you
smoke or inject them)
Transition: before physical examination:
Is there anything else you forgot to tell me about? .
Thank you for your co-operation, Ill wash my hands and Im going to examine you, Is
that OK?
B. Exam component:
Nystagmus: I
FO
Otoscopy, Rinne , Weber test
I ( mouth, , throat)
CV: A, orthostatic vital signs
Neurologic exam: Cranial nerves, muscle strength, DTRs, Romberg sign, tilt test
What you say when you do PE:
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
HEENT- Cranial nerves
Eyes:
17. Id like to examine your eyes now.
CN2:Cover your left eye with your left hand and read this row of letters .
- please, change the other side and read this row of letters.
CN 3, 4, 6: Please follow my finger without moving your head (Nystagmus) (EOM).
CN2 FO: I need to dim the light in this room. Im going to shine this light in your eyes.
Can you look at the clock on the wall. (Can you pick a point on the wall and look at it.). If
patient resists: I need to look at the blood vessels back there to make sure theyre not
damaged . It s extremely important for your safety.)
18. I need to check the inside of your mouth and your throat. Can you please open your
mouth. Please say ah (Cranial nerve10 ) and stick your tongue out and move it
from side to side (CN 12). And please, swallow (CN 9& 10).
19. I need to check your nose now.
20. I need to examine your ears now.
CN8: :( make a noise: snap lightly your fingers). Can you hear them both the same
way?
Weber: Im going to put this tuning fork on your head . Tell me if it sounds the same
in both ears.
Rinne: Let me put the tuning fork behind your ears. Tell me when you cant hear any
longer.
Can you hear now
CN 5: Please clench your jaws.( muscle of mastication)
Im going to touch your face lightly. Please close your eyes. Do you feel this
.Is it the same?(sensation)
CN 7 : Please lift your eyebrows.
Please smile and show me your teeth.
CN 11: Now turn your head and press it against my hands.
Please shrug your shoulders.
.
CV: Could you lie back on the table
1. Im going to examine your heart. Let me open your gown to uncover your
chest.
MRS
8. Please, Hold out your arms like this. Push up. Push down ( Shoulders)
9. Please, do this(elbow flexion). Pull in. Pull out.
10. Please, make the fists. Dont let me open them. ( Wrists).
11. Please, Spread your fingers apart. (Hands).
12. Please, Push your thigh up. Push your thigh down.( Thigh).
13. Please, flex your knee (Pull your legs in) and extend your knee (Kick your legs out).
14. Please, Push your foot up (dorsal flexion ). Push your foot down ( plantar extension).
Reflexes: (R)
4. Now I need to tap on your arms. ( biceps, triceps, brachioradialis).
5. I need to tap on your legs. (patellar, Archilles)
Now I need to tickle your feet lightly. (Babinski).
Gait:
1. Now, please stand up (DR have to pull out the footstool .) Please walk to me.
2. Turn around. And go back, please, walk heel-toe-heel-toe. (Tadem gait.)
Romberg:
1. Please, stretch your arms out to your side and close your
eyes.( Im in back behind you. Im ready to help you if you
feel unsteady)
Tilt test?
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having problem of your ear
3. However, there are also other conditions which could be causing your problem.
Such as hypotension due to dehydration, dizziness related to your posture, etc .
4.To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
Is that alright? Do you have any more questions?
Goodbye, Maam. See you later.
1.
2.
3.
4.
SH:
8. Whats your job?
9. Do you have any stress in your life?
10. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
11. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
CAGE :
Have you ever felt a need to cut down on drinking?
Have you ever felt annoyed by criticism of your drinking?
Have you ever had guilty feeling about drinking?
Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
12. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
B.Exam component:
Eye: FO
Neck:carotid bruits
Pulmonary: A
CV: A2, PMI,
Abd exam:A Pa Pa(kidney)
Exts: Edema ,
Pulse(peripheral)
Neurologic exam: DTRs, Babinskis sign,sensation,strength in lower exts
Say to patient on your examination.
Thank your for your co-operation. Ill wash my hands, and Im going to examine you. Is that
ok with you?
Eye: FO
Id like to examine your eyes now. I need to dim the light in this room. Im going
to shine this light in your eyes. Can you look at the clock on the wall. (Could you pick a
point on the wall and look at it.).
Neck: I need to listen to your neck.
Pulmonary Exam.
Posterior Chest.
3. I m going to examine your lungs. May I untie your gown
4. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
7. I need to lower your gown and listen to your lung continuously
Cardiovascular exam:
Lying down: Could you lie back on the table.
8. Let me adjust the table to raise your head .I need to take a look at your
neck.(JVD)Now look to the left.
9. Im going to examine your heart. Let me open your gown to uncover your chest.
Alleviation
9. Do you always use a condom or only sometimes? (Do you use a condom consistency
or inconsistency?)
Have you ever been tested for sexually transmitted disease?HIV?
SH:
7. Whats your job?
8. Do you have any stress in your life?
9. Do you smoke? How much, How often? (how many packs a day? How long have you
smoked?)
10. Do you use alcohol? (What do you drink? How much do you drink per week? How
long have you drunk?)
a. CAGE :
b. Have you ever felt a need to cut down on drinking?
c. Have you ever felt annoyed by criticism of your drinking?
d. Have you ever had guilty feeling about drinking?
e. Have you ever had a drink first thing in the morning( eye opener) to steady
your nerves or get rid of a hangover?
11. Do you use any recreational drugs? Or illicit drug? (What do you use? Do you smoke
or inject them)
12. Have you ever been tested for sexually transmitted disease? HIV test?
* Challenging
Pulmonary Exam.
Posterior Chest.
11. I m going to examine your lungs. May I untie your gown
12. Let me take a look at your back.
13. Can you say 99 for me, please.
14. Im going to tap on your back to check your lungs. Is that ok with you?
15. I need to listen to your lungs. Please, take a deep breath for me.
Anterior Chest:
1.I need to lower your gown and listen to your lung continuously
Cardiovascular exam: Could you lie back on the table.
5. Im going to examine your heart. Let me open your gown to uncover your chest.
6. I need to listen to your heart.
Abdominal exam.
5. I need to examine your belly now Let me uncover your stomach.
6. Im going to listen to your belly.
7. I need to press lightly on your stomach. Tell me if you feel any pain or discomfort
8. I need to press a little more deeply now.
. Exts:
I need to find any changes in your legs. ( Edema, Cyanosis)
C.Counseling:
1. Based on your information and the findings from your physical examination.
2. I think you might be having inflammation of the respiratoty system(Viral.upper
respiratory infection)
3. However, there are also other conditions which could be causing the cough.
Such as medication, infection, asthma, heart disease, gastro-esophageal reflux
disease, etc.
7. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
If you agree I suggest you have HIV test?
5. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options.
7. To protect your health.
You shouldnt have heavy exercise or any sports at least 3-4 weeks(Rt UQ abd
pain, EBV mononucleosis)
You should quit smoking.
Is that alright? Do you have any more questions?
9. Goodbye, Sir. See you later
9. Rheumatoid arthritis.
10. Reiters syndrome
11. Splinter/ foreign body.
Test:
1. 1.CBC with differential, ESR
2. X ray of foot and ankle, 3 views.
3. Bone density scan( Dexa)
4. MRI.
5. RF,ANA.
A. History taking. Hello Sir, Mr. Wang. Im Dr. Le Nice to meet you! (First I need to cover
you with the sheet. Is that comfortable)
(Dont shake) How can I help you today?
Would you tell me more details about your pain?
LiqorAAA OI LQL Qn P RAAA
15. When did your pain begin (start)? Onset
Where did you first feel the pain? (where did your pain begin?)
What were you doing when the pain began? What brings the pain on?
o Does the pain begin suddenly or gradually?
( If patient have the fall)Do you have injure from the fall? can you describe your
fall? After the fall were you conscious or unconscious? Does any one treat you badly
at home? Have you seen Doctor for that? Why not?)
16. How do you rate your pain on a scale from 1 to 10? (with one is least and ten is
most) Intensity
17. Please (can you) point to where it hurt? Can you show me exactly with your finger
where does it hurt? Location
18. Tell me what the pain feels like? May you describe what kind of pain do you feel
like? Quality
Is it sharp ,dull, burning ,pulsating, cramping or pressure-like?
19. Is(Was ) your pain continuous or does it come and go? Quantity
How many times do you have pain per day/week/month? ( How
often do you have pain?)
How long does it last for each episode (every time)?
20. Now, if compare with the onset, is the pain getting worse or better? P
21. Does the pain move around or stay in one place? Radiation
8, Does any thing increase the pain? (Does anything make the pain worse?
)Aggravation.
Association Besides your pain do you have any symptoms?
12. Did you notice any swelling or redness in your heel?
13. Did you feel tingling or numbness or loss your sensation?
14. Did you feel any weakness?
15. Did you have any change in your vision?
16. Did you have a sore throat ?
17. Did you have any change in your skin?
18. Did you have any pain in your other joints?
19. Did you ever have morning stiffness
B. Exam component:
Eye: conjunctivitis( if you suspect Reiters syndrome )
Inspect the foot: compare both feet term of I ,
Pa of entire feet for any point of tenderness ,
Check of the range of motion of the ankles & forefoot joints , check for pain & restriction
of movements: passive motion, active motion( ask the patient to do active dorsiflexion, and
plantar flexion) .
Other Joins( fast)
CV: A
Pulmonary: A
What you say when you do PE:
Im going to examine your eye.
Im going to examine your feet.
24. I d like to take a look first.
5. Im going to touch your feet.. Tell me if it hurts.
Passive:
1. I need to move your feet.. Is that OK? Tell me if it hurts. Ill stop immediately.
Active:
1.
Move your feet up. Move your feet.down.
Do this (put your heels touch the floor) Move your feet outside. Move your feet
inside.
Move your toes up. Move your toes down.
Muslse strength
6. Please, Push your thigh up. Push your thigh down.( Thigh).
7. Please, Pull your legs in (flex your knee ) and Kick your legs out (extend your
knee).
8. Please, Push your feet up (dorsal flexion ). Push your feet down (plantar
extension).
Reflexes: (R)
7. I need to tap on your legs. (patellar, Archilles)
Sensation
Im going to touch your arm lightly. Please close your eyes. Do you feel this .Is it the
same
Pulse:
I need to check the pulse in your legs.
Other joints:I need to examine another joints
Pulmonary: I need to listen to your lungs. Please, take a deep breath for me.
CV : Could you lie back on the table. I need to listen to your heart.
C. Counseling:
5. Based on your information and the findings from your physical examination.
I think you might be having inflammation (or a trauma) of your heel..
6. However, there are also other conditions which could be causing your heel pain,
Such as dislocation, fracture, injury of ligaments etc.
7. To have the exact diagnosis. I need to run some blood tests, urine tests, and imaging
studies.
8. Once I get the results of these tests.
Ill be in a better position to tell you your diagnosis and treatment options .
5. Is that alright? Do you have any more questions?
Goodbye, Sir. See you later.