STEP 2 CS Cases

SOB
I can see that you are in great distress. Is there anything that I can do to make u more
comfortable?
D/D:
Acute causes- CHF, Asthma
GERD
Bronchitis
Pneuomonitis
Foreign body

Chronic causes-COPD
Bronchiectasis
TB
Lung ca
ILD

Workup:
CBC
CXR
Peak flow measurement
PFTs
Methacholine challenge test
Sputum for gm stain and culture
D O P E F C AAA
A-is it aggravated on walking,sleeping or resting?
FNVTTTT

Associated symps: do u have SOB at rest? If no, how far can u walk b/f u get SOB?
Do u wake up at night because of SOB?
Do u use any pillows because of SOB? If yes, how many pillows?
Do u have any cough? If yes-CABCO
Do u have any wheeze, runny nose, facial pain?-URTI, Pneumonia
Do u haveTB symps?
Do u have any..GERD symps?
Are u getting your flu shots regularly?
Did u travel recently?
Do you have any.CHF symps?
Panic attacks-are u anxious of anything?
Closure and advice:
It could be- infection of your chest or exacerbation of your previous condition or long standing
smoking habit or hypersensitivity of your airways

CHEST PAIN
D/D:
CVS- MI, Angina, Pericarditis, Aortic dissection
Resp- Pleuritis, PE
GI- GERD, PUD, Gastritis, Diffuse eosophageal spasm
MSK- Costochondritis, Rib fracture, Muscle strain
Workup:
ECG
CPK MB, Troponin
CXR
CBC, electrolytes
Echocardiography
Cardiac catherization
Eosophageal ph monitoring
Upper endoscopy
CT chest for PE
D O P E C F C AAA
Associates symps:
CVS- do u have any SOB?? Excessive sweating? Nausea? Swelling of your ankle or feet? Rash
and joint pains? (RF or Coxsackie virus), Racing of heart, light headedness, passed out?
Do you have any GERD symps?
Resp- do u have any cough, wheeze, runny nose?
Do u have any pain in your legs while walking?-DVT and PE

PALPITATIONS
DD: code CHAPATIS
c-caffeine
h-hypoglycemia,HOCM,hyperventilation
a-anemia
p-panic attacks, phreochromocytoma
a-arrythmias,anxiety
t-thyrotoxicosis
i-induced by drugs
s-stress

Workup:
serum Glucose
CBC, electrolytes
TSH
BUN, creatinine
ECG, Holter monitoring

Patient c/o funny sensation/weird sensation in the chest or pounding or racing of the heart
D O P E C F AA
F-how long does each episode last
Regular or irregular
Ask all CVS and RS symptoms
Coffee- do u drink coffee? If yes, how many cups or times per day?
Anemia- any bleeding points in your body and LOC( passed out) and feeling tired?
Anxiety-are u anxious about anything? Any stress in life?
Hypogly-do u take your meals regularly? Did you ever skip meals? Any relation to meals?
Pheo-any headache, excessive sweating, weakness?
HOCM-any sudden death in the family?
F N VT T T
T-Thyroid- any excessive sweating, shaky mvnts of hands, any skin changes, heat intolerance?
Closure and advice: Please cut down on caffeine
Stress counselor-can help you by teaching relaxation teqs
If on thyroid hormone-have regular thyroid level check up and get the dosage accordingly
If hypoglycemic-donot skip your meals and have a regular diet

DYSPHAGIA
C-carcinoma eosophagus, CVA
A-achalasia cardia
G-GERD with stricture
E=eosophagitis(HSV,CMV, Candida, pill induced)
S-scleroderma or CREST synd
F-foreign body obstruction
MG-mystenia gravis
Z-zenkers diverticulum
P-plummer Vinson synd
Workup: Iron studies(TIBC, s. iron, s. ferritin), TSH, plain cxr, barium swallow, CT chest,
endoscopy with biopsy, eosophageal manometry, HIV testing, Anti-centromere antibodies
Associated symps: Do u feel food get struck?
Can u locate where u feel the food struck?
Do u have difficulty swallowing liquids or solids of both? If both, then with started first?
Do u have any pain while swallowing?
Do u have any water brash or heart burn?
Did u notice any food particles on your pillow when u get up from your bed?
Did you have any episodes of choking?
Do u have any drooling?
Do u have any halitosis?
Do your fingers change in color when exposed to cold or emotions? Did u notice any skin
changes?
Closure and adviceGrowth in your food pipe or infection, foreign body obstruction
Take soft foods slowly in small amounts. If problem with liquids then start IV line, GERD
counseling

HOARSENESS
D/D: Reflex pharyngitis
Vocal cord ca
Laryngeal ca
Vocal nodules or polyps
Vocal cord or Recurrent laryngeal nerve palsy
Hypothyroidism
Chronic laryngitis

Workup:
Indirect larnygoscopy
CBC
TSH
Upper GI endoscopy
24 hr ph monitoring
Xray neck-AP and Laterval view

GERD-heart burn/water brash/difficulty with swallowing, nocturnal cough

RLN palsy-any cough while swallowing or lying down?
VC palsy-any diffuculty with breathing?
CNS-difficulty swallowing, slurred speech, weakness in arms or legs
Tumor/ca-?
Closure and advice:

SORETHROAT
Code: U G H I P
D/D:
Infectous mononucleosis
Streptococcal pharyngitis
URTI
Viral pharyingitis
Bacterial pharyngitis
Acute Hiv infection
GERD
Workup:
CBC, peripheral smear, Monospot test
Throat swab for culture sensitivity
HIV ab and viral load
Anti EBV abs
VDRL and RPR
LFTs(AST, ALT, bilirubin, ALP)
Associated symps: Do u have any fatigue, diff swallowing, belly pain?-IM
Any fever, runny nose, cough, SOB?-URTI
Do u have any facial pain?-sinusitis
Do y have any ear pain or discharge?
Did u notice any swollen glands/LN/dysphagia? If yes, are glands painful?
Do you have any rash, joint pain?- Rheumatic fever
Do you have any change in color of urine?-GBS,GN
Do you have any GERD symps?
Closure and advice:Advice HIV testing, safe sexual practice
Avoid contact sports, strenuous exercise-To avoid the risk of splenic rupture

HEMOPTYSIS
D/D:
Pulmonary TB
Pulm edema
Bronchogenic ca
Bronchitis
Pneumonia
Pulmonary embolism
Lung abscess
AV malformation
Workup:
CBC, CXR, Blood cultures, UA/UC, Spiral CT, Lung biopsy, Bronchoscopy
D O P E F C AAA
C A B C O
Blood-dark colored or fresh blood or blood clots?
Associated symps: do u have any chest pain or SOB?-Heart symps
Do you have any wheeze?-Lung symps
How is your appetite? Do you have any evening rise of temp? Any ill contacts? When was your
last PPD?-TB symps
Have u been restricted to any one position because of hospitalization or travel?-PE
Closure and advice:

COUGH
D/D:
URTI
TB
COPD
Acute Bronchitis
bronchiectasis
Pneumonia
Bronchogenic carcinoma
Foreign body
GERD
Workup:
CBC
CXR
Sputum for gm stain and culture
PPD
D O P E C F AAA
A-is it worse during any part of the day/season/posture?
Do you bring up anything in your cough? Eg-phelgum. If yes-CABCO
Do you have any SOB? PND? Orthopnea? Ankle swelling? Palpitations(racing of heart),
Passout?-COPD, CHF
Do you have any runny nose? Facial pain?
Do you have any dripping sensation in your throat?
Do u have any soreness in your throat?
Do u have any wheeze?
Do you have any waterbrash? Heartburn? Belly pain?
Do u have any ..TB and GERD symps?
P A M H U G S F O S S
M-ACE inhibitors?
Closure: could be due to hypersensitivity of your airway
Advice: Dont indulge in activities that increase your breathessness
GERD-have meals 2 hours before going to bed, no caffeine, no smoking
Physiotherapist for breathing exercises
Use tissues when u cough
Use face mask when you r at work
Take adequate rest and nutrition and hydration
If u are allergic to anything, then avoid it

VOMITTING
D/D code: V O M I T I N G H
V- Vertigo
O-OBG(pregnancy), obstruction
M-Migraine, Motion sickness
I-Inflammation=Pancreatitis, pyelonephritis, cholechysitis
T-Treatment=chemotherapy, surgeries (paralytic ileus, adhesions)
G-gastroenteritis
H-hypercalcemia
Workup:
Urine HCG
Pelvic exam
U/S pelvis
CBC, electrolytes, Ca, Glucose
Urine analysis and culture
D O P E C F AAA
C A B C O
Associated symps:
Do u have any belly pain?-Gastritis
Do u have any back pain? Pyelonephritis, pancreatitis
Do u feel the room is spinning around you?-Vertigo
Did you eat food outside?-GE
P A M H U G S F O S S
M-chemotherapy?
U-UTI symps?
O-menstrual history; Is there any chance of you being pregnant?
Closure and advice:

BELLY PAIN
D/D: code GOPALSIR
G:GB-cholecystitis, choledocolithiasis
O: OBGYN-PID, Ectopic pregnancy, endometriosis, adenomyosis, ovarian cyst or torsion
P:Pancreas-Acute pancreatitis
A:Appendicitis
L:Liver-Amoebiasis, hydadid cyst, hepatic congestion
S:Stomach-GERD, PUD
I:Intesines-CD, UC, Diverticulitis, mesenteric ischemia
R:Renal stones, RCC
Workup:
Rectal exam
Serum Amylase and lipase
LFTS (ALT,AST, bilirubin, ALP)
Endoscopy for H.Pylori testing
Upper GI series
U/S abdomen
CT abdomen
U/S pelvis, Urine HCG
D O P E C F AAA
L I Q R
F N V T T T T
Do u have any occupational stress?
P A M H U G S F O S S
P-when was your last colonoscopy done?
H-any previous appendicectomy or PID history
U-do u have any burning sensation while passing urine? Did u ever notice blood in urine or what
is the color of your urine?-Nephrolithiasis
G-how are your bowel mvmts? How often do you pass your stools? Do u have any pain while
passing stools? Did you notice any blood in your stools? What is the color of your stools? Any
alternating bowel habits? = CABCO
Closure and advice:

10

BLEEDING PER RECTUM

D/D code: CHAD2IF
C-colon ca
H-hemorroids
A-angiodysplasia
D-diverticulosis, dysentery
I-IBD=UC and CD
F-fissure in ano

Workup:

D O P E C F AAA
C-do u have blood every time you pass stool? If no, how often do u pass blood? Ask for
CABCO-how much blood, color(altered or bright red), is it mixed with stools? Do u find mucus
with stool?
Associated symps:
How r your bowel habits?
Do u have pain while passing stools?
Do u have to strain while passing stools?
How frequently do u pass stools?
Is it alternating with diarrhea?
Do you any belly pain?
Do u have any sensation of incomplete evacuation?
Do u have to rush to bathroom to pass stools?
Are you passing any back colored stools?
Does your stools float in the pan?
Does it have any specific odor?
Did u notice bleeding from any other sites?
Did u ever undergo any colonoscopy?
Closure and advice:

11

HEMATURIA
D/D: code SHITTER
S-stones in bladder or ureter
H-hematologic
I-infection(GBS infections, Schistosomiasis)
T-trauma
T-tumor (RCC, Bladder ca)
E-exercise (rhabdomyolysis)
R- Renal(GN, PCKD)

Workup:
Genitourinary exam
Urine analysis and cytology
BUN, creatinine, PSA
PT, APTT
U/S renal bladder
CT abdomen and pevis
IVP

D O P E C F AAA
C-do u see blood everytime u pass urine? If no, then how often?
How much? When did u notice blood? i.e before/during/after/through out passing the urine
Associated symps:
Do u have any burning sensation?
Do u have to rush to the bathroom to pass urine? (urgency)
Do u have to get up in the night? (nocturia)
How is your stream? (any weak stream)
Do u have to strain to pass urine? (straining)
Do u have to wait before passing urine? (hesitancy)
Did you have any urinary injury?
Do you any dribbling or leaking of urine? (incontinence)
Did you notice any pus in urine?
Do you have any pain in your back? (flank pain)
Have u ever been diagnosed to have kidney stones? Have u ever passed stones in your urine?
Do you have any sore throat? Joint pains? Back pain?
Do you have any bleeding points anywhere in your body?
Have u exercised strenuously?
Closure and advice:

12

FATIGUE (Feeling low or feeling tired)

D/D: code HODCAMP
H- hypothyroidism, HIV
O- obstructive sleep apnea, occult malignancy
D-DM, depression, domestic violence
C-caregiver fatigue, compassion fatigue,colon ca
A-anemia, adjustment disorder
M-myasthenia gravis, malignancy
P-pregnancy, PTSD

Workup:
CBC, electrolytes, calcium
TSH
HIV and STD testing
Polysomnography
Noctural pulse oximetry
Colonoscopy

Associated symps:
Hypothyroidism- do you have any problems adjusting with surrounding temp? Do you have any
sonstipation? Any hair fall? Any hoarseness of voice? Any dryness of skin? Any belly pain or
discomfort(for constipation)?
OSA- Did anyone notice u snoring at night? Do you feel refreshed after waking up in the
morning? Do u feel tired and sleepy during daytime?
HIV and malignancy- How is your appetite? Do u have any recent weight changes?
Depression- How is your mood? If good, then ask for ICE >
How is your interest nowadays? What are your hobbies? Do u enjoy them?
How is your concentration?
How are you energy levels?
If mood is bad, then ask for GMPS
S- How is your sleep?
I- interest?
G-guilty?
E- energy?
C- concentration?
A- appetite?
P- psychomotor changes? (any irritability)
S-suicidal tendencies? (do u feel like hurting yourself?) If yes, then give suicidal counseling
DM- do u feel any increase in thirst and hunger? Do you feel any increase in frequency or
urination?
Domestic violence- are u being physically or emotionally hurt or abused by anybody? Are you
feeling safe or are u afraid at home?
Anemia-do u have any racing of heart? Any SOB? Any belly pain? Any bleeding points?
Adjustment disorder- do u have any stress at work or home?
Myasthenia gravis- did u notice any drooping of eyelids? Any double vision? Any increased
fatigue towards the end of the day?
PTSD-do u have any flashbacks or nightmares of any events?
It sound like u are losing hope. Have u ever thought of hurting yourself or try to do so?
Closure and advice:

13

HEARING LOSS
D/D code: MANFLOPIT
M-meniers disease
A-acoustic neuroma
N-noise indused
F-foreign body
L-labrynthitis
O-otosclerosis, ototoxic drugs, otitis media
P-presbycusis, perilympthatic fistula
I-impacted wax
T-trauma
Workup:
audiometry,
tympanometry
CT head
brain stem auditory evoked potentials
CBC, ESR, electrolytes, VDRL
Hello Mr.x, My nurse told me that u have problem with your hearing. Am I audible to you? Do u
want me to come closer. May I know in which ear u can hear me from this position? If both years,
then say sorry.
Be near to the ear in which the SP can hear and start your introduction: I am Dr.Ravi, the
attending physician in this medical center and I will be taking care of you today..
Associated symptoms:
Otitis media and labrynthitis-do u have any ear pain? If so then ask LIQR. Do u have any ear
discharge? (ask CABCO). Do u have a runny nose, sore throat, cough? Do u have any
imbalance? Do u have any ringing sensation in the ear? Do u have any fullness in your ear? Do
you have any feeling of room spinning around u?
Have u ever been exposed to loud noises?
Acoustic neuroma- do u have any headaches? Any facial pain or facial weakness? Do u have any
vision problems?
FB- did u insert any fb either accidentally or intentionally in to your ear?
Trauma- did u ever have any trauma to your ear?
Is there any h/o recent infection and treatment?
Ototoxic drugs- aspirin, HCTZ, aminoglycosides,
Do u hear words jumbled or distorted?
Can u locate the source of sounds?
Do u have any problem understanding speech?
Does it effect your life style?
F N V T T T T - did you have any airtravel recently or scuba diving?

14

Examination: do Rinnes, Webers, sinuses, CNs

Closure and advice:

Ear plugs- I can write a letter to your employer to shift u to noise free places.
It is obvious from my examination that you have hearing loss, but it could also be due to some
reversible causes. Treating them may restore your hearing and for that I need to rule out some
reversible causes.
Meanwhile, with your permission I will make an appointment with an audiometrist who can help
u with some hearing aids.
CQ: Am I going to be deaf?

15

DIZZINESS
D/D code: HOMBLAAPS
H-hypoglycemia
M-meniers disease
O-orthostatic htn
B-BPPV
L-labrynthitis
A-acoustic neuroma
A-arrythmias
P-perilymphatic fistula (trauma)
S-stroke
Workup:
M-VDRL, RPR
O-orthostatic vital signs
B-audiogram, dicks hallpikes maneuvure
CBC, electroly, blood sugar
CT head, MRI brain
Associated symptoms:
What exactly do u mean by dizziness?
D O P E C F A A A: A-position and time
H-Have u skipped any meal?
M-do u have any problem with hearing? Any ringing sensation in your ear? Any sensation of
room spinning around you?
L-do u have any ear pain? Ear discharge? Any runny nose? Sore throat? Cough?
A- do u have any headaches? Vision problems? Facial weakness?
A-do u have any racing of heart? Chest pain? SOB?
S-do u have any weakness or numbness or tingling anywhere?
Examination:

Closure and advice:

Do not change your position suddenly (donot get up suddenly from lying down or sitting down
position)
Use hand railings while u walk
Please dont drive or go unaccompanied when u go out
Do carry an I.d card with phone numbers of your loved ones
Avoid high altitudes

16

INSOMNIA
D/D: code GMCPROUD
G-generalized anxiety disorder
M-menopause, medications
C-circadian rhythm sleep disorders, coffee
P-PTSD, hyperthyroidism
R-restless leg synd
O-obstructive sleep apnea
U-UTI, BPH
D-depression, diabetes mellitus
Workup:
Polysomnography
MSE(mental state examination)
TSH
CBC
ECG,EEG
Urine toxicology
D O E F AA
D-when did it start?
I need to ask u few qs about your sleep pattern. Is that ok with you?
Do u have problems falling asleep?
Falling asleep-when do u usually go to bed? How much time do u take to fall asleep? What do u
do before u go to bed? Do u exercise? Do u take excessive coffee or alcohol before going to bed?
Do u watch tv? Smoke?
Do u have problems staying asleep?
Staying asleep-How many hours do u sleep? How many times do u wake up in the middle of the
night? What do u think is causing it?
Do you have problems like unusual waking up early in the morning?
UTI/BPH/diabetes mellitus-do u wake up to urinate in the middle of the night?
Anxiety- are u anxious about anything?
GERD-.(ask GERD symps)
Menopause- do u have any hot flashes? Excessive sweating?
Circadian rhythm-do u have any recent changes in work shifts?
PTSD-do u get any nightmares or flashbacks of those events?
Restless leg syndrome- does any one notice frequent mvmts of your legs during your sleep?
OSA-do u feel sleepy during daytimes? Do u feel refreshed after u wake up in the morning? Do u
feel sleepy during the day? Did anyone notice u snoring when asleep?
Depression-how is your mood?
If good, then ask interest,conc, energy levels(ICE)

17

If bad, then ask SIGECAMPS

Examination:
In CNS, do MMSE (i.e OMCJ)
O-orientation(time,place,person)do u know what time of the day it is? Do u know where are u
know? Do u know who I am?
M-memory(remote,recent,immediate) what is your date of birth? What did u have for lunch
yesterday? Ill tell you the name of 3 things, please repeat them for me
C-concentration-Can u spell the word book backwords for me?
J-judgement-what will u do if u see a cloth catching fire?
If you dont have time for MMSE, ask the pt whats his name? where are you? whos the
president of US? What day is today?
Closure and advice:
Please maintain a sleep diary
Follow regular bedtime and wakeup times
Dont exercise in early evenings
Donot take caffeine or alcohol and donot smoke before going to bed
Please avoid watching tv on bed
Avoid daytime naps

18

HEADACHE
D/D: code CARMST4P4
C-cluster headache, cocaine
A-anesthetic withdrawal
S-sinusitis, subdural hematoma, SAH
R-refraction headache
M-migraine,meningitis
T-tension headache, tumor, trauma, temporal arteritis
P-pseudotumor cerebri, prolactinoma, phreomochromocytoma, premenstrual synd
Workup:
CBC, ESR, electrolytes
CT or MRI brain
CT of PNS
LP
Cluster-do u have pain around your eye? Any watering of eyes? Any runny nose?
Migraine- do u have any warning signs(nausea,vomiting) b/f the onset of headache? Do u have
any discomfort with bright light?
Meningitis-do u have any neck stiffness? Do u have any ear pain? Ear discharge? Did u ever
throw a fit?
Refraction and tumor-do u have any vision changes? Do u have any stress at work?
Temporal arteritis- do u have any jaw pain while chewing?
Trauma- did u have any trauma to your head?
Sinusitis-Do u have any runny nose? facial pain?
Pseudotumor cerebri- do u have any weakness in your arms or legs? Any tingling or numbness or
weakness in your arms or legs? Do u have any difficulty in swallowing? Any slurred speech? Any
changes in vision? Any urinary or stool incontinence?
F N V T T T (trauma and tumor)
PAM H U G S F O S S
M-oc pills, vitA toxicity, tetracycline toxicity
O-occupational stress
Examination: head, CNs, MRSP(UC)
Closure and Advice:

19

LOSS OF CONSCIOUSNESS (LOC)

(Pt c/o faint episode, pass out or blackout)
D/D: code HOTASVD
H-hypoglycemia, heat exhaustion, hypovolemia, HOCM
O-orthostatic hypotension
T-tumor, trauma
A-arrythmias, anemia, aortic stenosis
S-stroke, TIA, SAH,seizures, substance induced(cocaine)
V-vasovagal syncope, vertigo
D-drug induced
Workup:
Blood glucose
Serum electrolytes, CBC
Orthostatic vitals
CT or MRI brain
EKG, ECHO, Holter monitoring
EEG
Urine toxicology
D O P E- (E-do u relate this problem to any event?)
Associated symps:
Is this the first episode/If no, how many previous episodes?
For how long did u lose your consciousness?
Did u lose your consciousness b/f or a/f your fall?
Seizures-did u smell, see or hear anything unusual or any warning signs b/f the event? Did
anybody notice shaking or jerky mvnts of your body? Any tongue biting? Any frothing? Did u
pass any urine unknowingly?
CVS-did u have any racing of heart? Any chest pain?
Stroke or TIA-did u have any light headedness? Any weakness or tingling or numbness in your
body?
Hypoglycemia-did u have any excessive sweating? Did you skip any meal b/f this event?
Heat exhaustion-did u notice any dry mouth b/f the loc?
Vertigo-did you any spinning sensation or ear pain? Do you have any problem balancing while
you walk?
Trauma-did u have any trauma to your head?
HOCM-have you exercised strenuously b/f u lost your consciousness?
Hypovolemia- did u have any loose stools recently?

20

(After the event)- did you have any confusion? Any numbness? Any tingling? Any
headache/nausea (hypoglycemia) after the event?
In family history, ask for any sudden deaths
Examination:
If hypertension present, do CVS
If seizure activity, do CNS and HEENT
Closure and advice:
Please dont drive or go unaccompanied when u go out
Do carry an I.d card with phone numbers of your loved ones
Avoid strenuous activities, exercise
Avoid illicit drugs
until I get your results
CQS:
My wife asked me to drive car, can I?
Did I pass out due to cocaine?
Can I go play a match?
Is this the same attack as that of my brother? (HOCM)

21

CONFUSION OR FORGETFULLNESS
D/D: code VANISHED
V-vascular dementia, vitB12 deff
A-alzheimers , AIDS
N-NPH, neurosyphilis
I-intracranial tumors, infection
S-SIADH, chronic subdural hematoma
H-hypothyroidism, hypoglycemia
E-encephalitis, electrolyte imbalance
D-depression, drugs, diabetes mellitus
Workup:
MSE
CBC, ESR, electrolytes
CT or MRI brain
Serum B12 levels
Doppler U/S carotid
RBS,BUN,creatine
LP with opening pressure
If family members tell you about it, then ask since how long he/she has been concerned about
this.
DOP E
Did u or anybody notice it?
Is it affecting your daily activities?-code DEATHSHAFT
Do you have trouble with dressing? Eating? Accounts management? Toileting(using restroom)?
Managing shopping? House keeping? Accounting? Going around or finding home? Cooking?
Travel or driving?
How is your mood? Ask for ICE and SIGECAPS
CNs-do u have any problem with speaking? Swallowing? Vision?
Motor-do u have any weakness in your body?
Sensory/vitB12-do you have any tinging or numbness?
ANS-do u urinate or pass stools without your knowledge?
Gait- do you have any trouble with balancing while u walk?
Tumor-do u have any headache?
Did you ever throw a fit?
Ask for...hypothyroidism, hypoglycemia symps?
Whom do you live with? Do u have anyone to take care of u in case of emergency?

22

With your permission, I need to talk to your family members to better understand your problem
Examination: MMSE, CNS, MSRP(motor,sensory,reflexes,pulses)
Closure and advice:
You have some problem with your concentration and memory. It might be due to a problem in
your brain or with the vessels supplying your brain or but there are also many other possibilities.
So I need to run down a few blood tests and imaging studies of your brain
Keep things organized in your room
Maintain a diary listing your activities
Donot drive alone
Always be accompanied by others when u go out
Please carry an i.d with contact numbers of your loved ones
CQ: is it because I am getting old? Well, I can understand..Getting old doesnot mean you
have to have forgetfulness. It could be one reason but there are also several other causes which
need to be ruled out and some of them can be effectively treated. In order to be sure I need to run
down a few tests..

23

WEAKNESS IN ARM OR LEG

DD:
TIA
Complicated migraine
Intracranial neoplasm
Chronic subdural hematoma
Hypoglycemia
Diabetic peripheral neuropathy
Alcoholic-B12 deficiency
GBS
MS
Radiculopathy

Workup:
CT head, MRI brain
Doppler U/S carotid
RBS, HBA1C levels
Serum B12 levels
Nerve conduction studies
CBC, ESR, electrolytes

C/O weakness in arm or leg

D O P E C F AA
P- proximal to distal
Distribution: which parts of body are involved?
Sensation: any tingling or numbness? Any pain? Any headache? Any neck pain? Any back pain?
If headache positive then rule out migraine
Seizures: did you ever throw a fit?
CN-any difficulty in swallowing? In speech? In breathing? In vision?
ANS-did you ever pass urine or stools unknowingly?
Hypoglycemia-did you ever skip your meals?
FNVTTT
T-trauma(subdural or epidural hematoma)
PAM H U G S F O S S
P-DM, HTN, Atherosclerosis
Closure and advice:
Appointment with a physiotherapist

24

AUDITORY HALLUCINATIONS
D/D: code BADSSN
B-Brief psychotic disorder(<1mnth)-due to medical/psychological/electrolyte imbalance
A-adjustment disorder
D-drug/substance induced psychosis
S-schizophreniform disorder (1-6 mnths); if >6mnths then its schizophrenia
S-seizures
N-narcolepsy
Workup:
Urine toxicology (drugs)
CT head and MRI brain
CBC,ESR, electrolytes
BUN, ser creatinine, ALT,ALP,AST
Schizoaffective disorder schizophrenia + mood disorder i.e either depression or mania
Mr.X, my nurse told me that you are hearing voices. Please donot listen to them. They are
imaginery (not real). Please concentrate on me Mr.x. I am here to help u and I can do that if you
share your problem with me. I assure you that everything we discuss will be kept confidential.
To interrupt the ptExcuse me Mr.x, I am sorry to interrupt you. I know these things are bothering u. I need to focus
completely on your present situation. Please dont concentrate on them, try to concentrate on me.
I understand that you are going through a tough phase. We will definitely work on it together.
Do u hear those voices even when you close your ears?
Do you think voices are controlling you?
DOPEF
Auditory-how is it affecting your daily activities?
How many voices do you hear?
Where do u think they are coming from?
Are u familiar with those voices?
What do they say?
Visual-do you see something that others dont? What do you see?
How long have u been having this problem?
Olfactory-do you smell anything that others dont?
Sensory-do you feel something crawling on your body?
Suicidal tendency-did you ever think of hurting yourself/others?
Do you have any pills/guns in your house?
Delusion-do you have beliefs that others find odd?
Mania-do u feel elated?
Mood-how is your mood?-ICE and SIGEMCAPS

25

Relationship-how is your relationship with the family? Are they helpful?

Do you have anyone to share your feelings with?
Any weakness/numbness/tingling/incontinence/slurring of speech/headache/seizures
Examination:
MMSE
CNS
Neck-carotid auscultation
CQ:Am I going mad?
Mr.x, I can understand your apprehension. Hearing voices doesnt mean that you are going mad. I
have seen many cases of this kind, who are doing well now. But to be sure of the diagnosis, I
need to run down some tests. Please dont worry. Whatever may be the Dx, I am here to help you
out and give u the best Rx options available at our hospital.

26

JOINT PAIN:
D O P E C F AAAL I Q R
Associated symps:
Did you notice any redness or warmth or swelling or stiffness?-(inflammatory signs)
Do you hear sounds while moving your joint?
Do u have any decreased movent at the joint?
Did you do any vigorous exercise?
Did you lift any heavy weight?(for back pain)
Is it affecting your daily activities?
Are there any similar symps in other joints?
Motor:
Do you have any weakness anywhere in your body?
Sensory:
Do you have numbness, tingling? Or pain elsewhere in your body?
Autonomic:
Did you ever pass urine or stools without your knowledge?
Multiple myeloma-do you have light headedness? Constipation? Racing of heart?headache? belly
pain?(ask only if back pain)
FNVTTTT
F-any fever?(septic arthritis)
T-did you have any trauma to your joint?
T-tumor-prostate,lung,breast,multiple myeloma,lymphoma
CITRUS HPT
C- runny nose, cough, chest pain?-(viral infection)
I-infection?-(UTI)
T-tick bite?
R-any rash on your body?
U-any ulcers on your body?
S-any stiffness of your joints?
H any hair loss?
P-any photosensitivity?
T-temperature: any changes(color) of fingers on exposure to cold?
PAM H U G S F O S S
M- steroids, HRT,vitD?
U-UTI?
S-any disturbed sleep in lying down position?
O-menopause, IUD insertion
S-erections/ejaculations problems?
Examination:
Start with the normal joint

27

Inspection-look for any redness, swelling or abnormalities?

Palpation-feel for any warmth,tenderness and for range of movements(say to do as much as
possible but dont exert your self. If you get any pain, please stop immediately)
For spine-untie 2nd knot only and say can u pull the gown sideways? Now palpate for spinal and
paraspinal tenderness.
MRSP
For back pain-now I would like to do a special test called SLRT and for this you need to lie
down? Is that ok with you?
Could you please lift your leg(either rt or lt) without bending at knee?
BACK PAIN
DD:
Males:
Lumber disc herniation
Lumbar muscle strain
Lumbar spinal stenosis
Osteoporotic/vertebral fracture
Prostate ca metastasis

Females:
Secondaries in spine
Lumbar disc herniation
Vertebral compression fracture
Osteoporotic compression fracture
Lumbar spinal muscle sprain
Paraspinal muscle sprain
Lumbar spinal stenosis
Lumbar spondolysis

Workup:
Rectal exam
Xray spine(AP and Lateral view)
MRI spine
PSA
DEXA scan
Serum ca, phosphate and ALP
CBC, ESR, electrolytes
Serum and urine protein electrophoresis
Closure and advice:
Donot involve in any strenuous activities which increases your discomfort
Dont strain your back
Take adequate rest (for back pain).
Give rest to your joint(for any joint pain)
Take/continue vitD and calcium supplements
Bend at knees instead of back while picking up objects-(demonstrate and explain ROM exercise
Once results are out, with your permission I will take an appointment with my physiotherapist
who will teach you exercises to increase range of mvts of your back and strengthen your back
muscles.
Prostate-back passage examination in the later part of the day

28

NECK PAIN:
D/D:
Paraspinal muscle strain
Cervical spondylosis
Cervical disc prolapse or herniation
Radiculopathy
RA
Traumatic fracture of cervical spine
Degenerative disease-Osteoarthritis of cervical spine

Workup:
Xray neck-AP and lateral view
Nerve conduction studies
Serum ca phosphate and ALP
CBC, ESR, serum electrolytes
Serum ANA and RF

For neck pain, shoulder pain, elbow pain-dont give shake hand
For neck pain-first knot only
Closure and advice:

CALF PAIN (DVT)

DD:
DVT
Cellulites/myositis
Ruptured bakers cyst
Hamatoma
Rupture of medial head of gastronemius
Spasm due to injury or sprain
Claudication
Workup:
Dopple U/S
CT chest, V/Q scan
D-dimers
Hypercoaguability testing
CBC and DC, ESR
CPK and myoglobin levels
CT venography
MRI leg(muscle/tendon rupture)
Blood for C/S
D O P E C F AA
LIQR
Associated symps:
Did you notice any redness in your legs? (rubor)
Do you have the sensation of warmth in your legs? (calor)
Do you have any swelling in your legs?(tumor)
Loss of function-Are you able to more your knee joint?(dolor)

29

Varicose veins-Did you notice any enlarged or dilated vessels on your legs? Any ulcers on legs?
PE-Do you have any SOB? Any chest pain? Any cough?
FNVTTTT
F-(DVT, cellulitis and myositis)
T-trauma(any immobilization?),T-travel, T-tumor(hypercoaguability state)-precipitating factors
for DVT
PAM H U G S F O S S
P-previous h/o arthritis (RA)
M-ocps precipitate clotting
H-orthopedic surgery(immobilization)
F-cholestrolemia, clotting disorders
O-pregnancies, immobilization
S- iv drug use
S-smoking(increases clotting), sedentary occupation (if elderly )
Examination:
Inspection-look for any redness, swelling or abnormalities?
Palpation-feel for any warmth,tenderness and for range of movements at knee (say to do as much
as possible but dont exert your self. If you get any pain, please stop immediately)
Elicit Pratts sign(sqeezing of posterior calf causes pain) and
Homans sign(passive dorsiflexion of foot causes pain in calf)
CVS and RS auscultation for PE
MRSP- P-lower limb pulses
Closure and advice:
Your condition could be due to a clot in the blood vessel or any infection.
If your results slow cots, we will start blod thinners which prevent further complications such as
clot traveling to your legs
Avoid immobilization for long period of time
Try to move in place and perhaps take a short walk
If on OCPs, please stop using them as this may worsen the condition.
Studies have shown that obesity increases your risk of having a clot. So, I suggest that you
exercise regularly and manage your diet

30

DIABETES MELLITUS FOLLOW UP

Well Mr.x, I am glad that you are here. I appreciate that you are taking good care of your health.
How can I help you?
Patient here for a refill:
I am glad to help you. Before I refill your medication, I need to ask you some qs and do a small
physical examination.
When was it first diagnosed?
May I know what medications you are on?
Are you compliant with your medication?
When was your last doctor visit? May I know the result?
Do you check your glucose levels regularly at home? May I know the readings?
Retinopathy-Do you get your eye check ups done regularly? When was the last check up done?
Do you have any blurring of vision? Do you have any headaches?
Neuropathy-Do you have any numbness, weakness or tingling sensation?
Do you have problems controlling your urine or stool?
Do you have any ulcers or repeated injuries to your legs?
Atherosclerosis-Do you have any chest pain? Any excessive sweating? And lightheadedness? Any
belly pain?
Urination-Do you wakeup at night? If yes, how many times? Is it disturbing your sleep?
Do you have any burning micturition?
Sexual dysfunction-Do you have any problems with your sexual life?
Do you have any early morning erections?
PAM H U G S F O S S
Examination:
Fundoscopy
Neck, CVS, Pulmonory
Abdomen
Extremities and Neurological
Workup:
HBA1C levels
BUN, Creatinine
CBC, s.electrolytes
Closure and advice:
Regular eye checkups
Take small frequent meals and please donot skip meals
Use soft heel pad shoes
Dont injure yourself. If injured take proper care as early as possible
Take a diet low in salt, carbs and fat and high in fiber
Exercise regularly

31

FEMALE CASES
VAGINAL BLEEDING
D/D: AVPBLEED
A- adenomyosis, abortion
V-vaginal injury
P-PID, PCOD, perimenopause
B-bleeding diasthesis
L-leiomyomas-heavy painful menstruation, dysperunia,
E-ectopic pregnancy
E-endometriosis,endometrial ca
D-DUB, hypothyroidism
Workup:
Pelvic, genital and rectal exam
Urine HCG, US pelvis
Cervical cultures, endometrial biopsy
PAP smear
PT/APTT
LH/FSH, prolcatin,TSH
Quantitative serum HCG
D O P E F AA
F-is it continous flow or is it spotting?
Is this the time when you usually get your period?
Associated symps:
Do you have any pain associated with bleeding? If yes, LIQR. Is it bright red or does it have
clots? Does it contain any tissue like substance?
V-did you have any trauma or accident?
B-do you have any belly pain? Do u have any racing of heart? Ankle swelling? Pass outs? Do you
have any bleeding points in your body?
A-when was you LMP? If LMP>5 wks, are there any chances of you being pregnant? Are you
cycles regular? How often do you get them? How many days do you bleed? How many pads do u
change on a healthy day? Do u notice any intermenstrual spotting? Any pain during
menstruation? When was your PAP smear done? If no then give advice. If yes, can I have the
result?
P-(PID)do you have any vaginal discharge? If yes CABCO
Do you have any vaginal ulcers? Any dryness? Any itching?
Perimenopause-Do you have any hot flushes?if flushes yes, then did u try any medication for it?
Endometriosis-Do you have any pain during menstruation? During intercourse? During
urination? During passing stools?
Endometrial ca-Did u notice any bleeding after intercourse?
Orthostatic hypotension-difficulty breathing, dizziness, lightheadedness, heart racing, chest pain

32

OBS-have u ever been pregnant before? Do you have any kids? How are they delivered?
Did u have any complication during pregnancy? During delivery?
Did you have any miscarriages?
F N V T T(thyroid*) T(tumor*)
P A M H U G S FO S S
M(blood thinners*)
F(bleeding disorders, multiple abortions*)
S(cocainevasoconstrictionabortion*)
Closure and Advice: Pt has dizzinessYour condition appears to be an emergency for me. Please dont take anything by mouth until the
investigation results are out. My nurse will be checking for your vitals regularly.
It can be due to complication of unknown pregnancy, abnormal hormone levels or any infection.
Maintain genital hygiene (practice safe sex), take plenty of fluids, take adequate rest
Dont involve in activities that increase discomfort
Iron and calcium supplementation

AMENORRHOEA
D/D: PPPPPPTAA or A2TP6
P-pregnancy, premature ovarian failure synd
P-prolactinemia(hyper)
P-PCOS
P-perimenopause
P-pills
T-thyroid disease
A-ashermans synd
A-anorexia nervosa
Workup:
Pelvic and breast examination
Urine HCG
Serum LH,FSH
TSH and prolactin
US abdomen
CT head
CBP, ESR, electrolytes
Ask only duration
D-drynesspremature ovarian failure
When was your last LMP? Hot flashes?
P-pregnancy-do you feel nauseated or did you ever throw up? Do u feel fullness of your breast?
Any discharge from your breast? Are there any chances of u being pregnant?

33

Perimenopause and Premature ovarian failure- do u have any hot flashes? Any night sweats? Did
u notice any mood changes recently/ do u feel irritable? any pain during intercourse? Any dryness
in your private parts?
Prolactinemia do u have any headache? Any vision problems? any nipple discharge?
PCOD-did u notice any excessive hair growth on your face?
Thyrod- Qs
Anorexia nervosa- any weight changes?
Premature ovarian failure and perimenopause- any hot flashes? Dryness in private parts?
Depression?-if mood good then ask ICE. If bad ask SIGEMCAPS
Post pill amenorrhea-are you using any OCPs?
Examination:
Belly
Occular mvnts,visual fields-(pituitary tumors,hyperprolactinoma)
Reflexes(hypothyroidism)
Pelvic exam- In the later part of the day
Closure and advice:
Exercise to reduce weight(PCOD)
Calcium and iron supplementation
Involve in pleasurable activities(menopause)
CQ:
Unplanned pregnancy?
I understand your anxiety about this unplanned pregnancy. I advice you to discuss this with your
husband. As your physician, I want to assure you that I am here to support and advice you
regardless of the decision you make. If you wish, I would be happy to discuss your options with
both of you.
Can I take HRT?
I can understand your concern. Once the results are out, I will be in a better position to tell you
what exactly is causing your problem. If your condition requires HRT then I will be more than
happy to prescribe it to you.

34

VAGINAL DISCHARGE
D/D:
Bacterial vaginosis
Candidial vaginitis
Trichomonas vaginitis
Cervicitis(Chlamydia and gonorrhoea)
Urethritis
PID
Workup:
Pelvic examination
Wetmount and KOH preparation of vaginal discharge
Cervical cultures, NAAT, USD abdomen
Urine for C/S
Urine for BHCG
D O P E F C AAA
C AB C O
Do u have any ulcers in your private parts? any dryness of your private parts? any itching of your
private parts?
Do u have any pain during intercourse?
Urethritis-do you have any B F U N S H I P?
B-burning, Frequency, urgency, nocturia, stream/strain, incomplete evacuation, pain or pus
Gonorrhea- do u have any rash on your skin? Any joint pains?
F N V T T T(T=any trauma to your private parts?)
Medications-any OC pills or any steroid use?
Examination:
Belly ex, CVA tenderness of UTI
GE-look for mouth ulcers or sores
Closure and advice:
It could be due to an infection of your private parts or infection of your urinary tract or any
complication of pregnancy.
Maintain proper hygiene of your private parts(wash regularly and keep it dry)
Practice safe sexual methods
Take plenty of fluids, nutritious diet, adequate rest
If ER case: your condition seems to be an emergency. Please donot take anything by mouth until
the instructions are passed. Once I am done with this, I will send my nurse to monitor your vitals
and give you IV fluids and appropriate medications.

35

DYSPAREUNIA
D/D:
Vulvodynia
Vaginismus
Atrophic vaginitis
Cervicitis
Endometriosis
PID
Depression
Domestic violence
Workup:
Pelvic exam
KOH and Wetmount preparation
Cervical cultures
U/S pelvis
laproscopy
D O P E F C A A A and D U D I
F N V T T T and P A M H U G S F O S S
DUDI
Do u have any discharge? Any ulcers? Any itching? Any dryness in your private parts?
Do you have any belly pain?(for cervicits, endometriosis, and PID) and ask for these respective
symptoms
Are u safe at home?
Ask for mood and relations
Closure and advice:

CQ: why are you asking me this question( are u safe at home?)
I am concerned that domestic maybe involved and my goal is to make sure that you are in a safe
environment and not a victim of abuse.

36

SNAPPING (Being irritable for silly things)

DD: code MGHASOM
Menopause
GAD(generalized anxiety disorder)
Hyperthyroidism
Anemia
Sleep disorder, sexual problem
Occult malignancy
Workup:
Serum LH, FSH
Serum T3, T4, TSH levels
CBC, ESR, electrolytes
Serum iron studies and HB
Menopause-Ask for menopause symptoma
GED-are u anxious about anything? Do you have any stress in your life?
Anemia- do you have any bleeding points? Any racing of heart? Any dizziness?
Hyperthyroidism? Any excess sweating? Any shaky mvts in hands? Any irritability? Any problem
adjusting to surrounding temp? Any appetite and weight changes?
Occult malignancy-any appetite and weight changes recently?
Sleep disorder-do you snore? Totally, how many hours do you sleep?
Whom do you live with? How is your relationship with them?
GE:
Thyroid and pulses
CVS
Lungs
DTRS increased in hyperthyroidism
Closure and advice:
It may be due to hormonal changes or normal changes with aging?
Be involved in pleasurable activities
Spend time with your loved ones(friends and family)
Take iron and calcium supplementation
If stress present, appointment with stress counselor

37

INCONTINENCE
D/D: code SOUND
S-stress incontinence
O-overflow incontinence
U-UTI, urge incont
N-Normal pressure hydrocephalud
D-DM and DI
Workup:
Pelvic exam
Cystogram
Urodynamic study
UA and culture
Qtip test
CT head
RBS HBA1C
D O P E F C AAA
F-how often do you have these accidents? Is there any specific time or event associated with
these accidents?
Does it affect your daily activity?
Does it affect your sexual life?
Does it affect your interpersonal relationships?
Do u use any absorbent pads? If yes, how many?
Ask for BFUNSHIP (but dont ask for stream)
Do u have any vaginal discharge?
Did u ever throw a fit? Any headache? Any weakness of your limbs?-NPH
Do u have any increased frequency of your urination and how is your thirst?-DM
FNVTTTT
T-any trauma to your back or private parts?
OBS:
How many pregnancies did you have? What was the mode of the delivery? Forceps or NVD or
CS?
Closure and advice:
Empty your bladder as frequently as possible.
Try to take an aisle seat while you travel
Cut down on your alcohol and caffeine
I advice you to use absorbent pads.
With your permission I would like to appoint a physiotherapist who can teach you some
strengthening exercises for you pelvic muscles and I will be there through the procedure.

38

IMPOTENCE or SEXUAL DYSFUNCTION

D/D: code DSPHAT
D-DM, drugs(Beta blocers, diuretics), depression
S-stress induced, stroke
P-performance anxiety, post MI, pituitary dysfunction
H-htn
A-atherosclerosis
T-trauma to back
Workup:
Genital and rectal exam
BS, CBC
Stamp test
S lipids, pelvic Doppler
S Testosterone
RBS
D O P E F AA
F-do u have this problem every time you perform sex?
How is your desire?
On a scale of 1 to 10, with 1 being flaccid and 6 being just able to penetrate, how do u grade your
erection?
Do u have any problem with ejaculation?
Did u observe early morning erections? (if yes-performance anxiety)
Are u anxious about sex?
Who is your partner?
Do u have any other partners? If yes, do you have this problem with all the partners?
If no, how is your relationship with your partner?
Ask for D U D I symptoms
Pituitary- do u have any headache? Any vision changes?
CNS-do u have any weakness or numbness or tingling anywhere in your body?
ANS-do u pass urine without your knowledge? Do you pass stools without your knowledge?
Atherosclerosis-do you have any pain in your legs when walking?
Depression-how is your mood? If good, ask for SIGEMCAPS
FNVTTT
T-any trauma to your back or private parts?
Do you any stress at work?
Do you use Viagra or sildenafil?
Examination:
CVS-back
CNS- Lower limbs-MRSP

39

PEDIATRIC CASES
For an emergency case (child is in ER and mother in examinees room)
CQ: doc, my child is in ER. Lets go and see my child now.
I am really very sorry that your child is in ER. I can understand that you are very anxious about
your childs health, but donot worry, your child is in safe hands. We have a very good intensive
care team at our hospital who will take care of your child very well. Your emotional stability is
very important for your childs health, please be strong.
To know more about your childs problem, I would like to ask you few qs and write down notes
while we talk. I assure you that I will be as quick as possible. So please bear with me for some
time. As soon as I am done with my qs, I will go and examine your child personally. Is that ok
with you? Shall I proceed?
Ok Ms.X, I am Dr.Ravi the attending pediatrician at this medical center and I will be taking care
of your child today..
What is your childs name? how old is he/she?
May I know why is he in the ICU?
Mother gives complaint..
Show empathy..
Can you tell me more about your childs problem?
D O P E C F AAA
Child at home and mother in room:
Hello Ms.X, good morning. I am Dr.Ravi, the attending pediatrician at this medical center. Nice
to meet you.
What is your childs name? how old is he? Where is he right now? Who is taking care of him?
Ok Ms.X, how can I help you?
Mother gives complaint.
Give empathy..
Can you tell me more about your childs problem?
D O P E C F AAA
CQ: doc, why are you so late. I have been waiting for you since a long time.
I am very sorry for the delay Ms.X. I was encountered with some unexpected delay. Now I am
here with you and I assure that I will give my uninterrupted attention.

FEVER
Phone case:
Hello, I am dr.ravi, the attending pediatrician/physician at this medical center and I will be taking
care of your call today.
May I know who I am speaking to? How is he/she related to you? With whom is the baby staying
with?
Ok Ms.x, how can I help you?
I am sorry to hear your childs problem. I will do my best to help your child in this regard. For
that I need to ask few qs and make a short note while we discuss. Is that ok with you?

40

Ms.X, if there is a pause in my conversation, please understand that I am making a note. So

please dont hang up the phone.
What is your childs name? Is it a baby boy or a girl?
How old is your child?
Where is the child now?
Can you tell me more about your childs problem?
Fever:
Did you record the temperature? If yes, may I know the reading? If no, is it lowgrade or high
grade?
Is it associated with any chills or rigors?
Is it associated with any sweating?
Did you intervene in any manner? any medication like Tylenol?
URTI:
Does he have any runny nose?
Any cough?
Any fast breathing?
Any ear discharge or ear pulling? If yes, does he have any hearing problem?
Any watering from eyes?
Any difficulty swallowing?
Rash:does he have any rash? If yes, where and how does it look like?
Diarrhea or vomiting:
Code ONCALLIDIOT
O-Onset,
N-number,
C-cry/cough/consistency,
A-associated symps-eg:URTI symps,rash,etc.,
L-listlessness,
L-liquids-urine and intake output,
I-immunization,
D-diet,dehydration,development,daycare, doctor visit
I-infections in family or ill contacts
O-ORS
T-travel
GIT:stools-how many stools does he pass per day?
How many soiled diapers do you change per day?
Did u see any blood in it?
Did u see any worms in it?
Whats the color of the stools?
Whats the consistency? (watery/semisolid)
Is it foul smelling?
Does he cry while passing stools?
Did he vomit or throw up?
Is there any difficulty with swallowing?
Did u notice any belly distension?

41

Does the child seem to be having any belly pain? (like, does he hold his belly while crying?)
Urine:
did u notice any change in his urinary habits?
How many wet diapers do u change per day?
What is the color of the urine?
Does he cry while passing urine?
Seizures:
Did u notice any shaky mvnts of the body?
Dehydration:
Did u notice any dry mouth or dry skin?
Did u notice any sunken eyes?
Did u notice any sunken soft head on his head?
How is his skin turgor? Is it moist or dry?
Activities:
Can u tell me more about his activities?
Does he look active and playful/dull and lethargic/irritable?
If dull, is he awake and responsive?
Food:
What kind of food do u give him?
Is there any change in his food recently?
How is his appetite?
Did u notice any changes in his weight?
PAM H U G S F
TBIIDERS
T-did he travel anywhere recently? Was your child ever injured?
B-birth history:Now I would like to ask you few qs regarding little johns birth.Is that ok with u?
(During pregnancy)-did u smoke? Drink alcohol? Use ilicit drugs during pregnancy?
Did u have routine checkups during pregnancy? How often?
Did you take MVT supplements and vaccine shots during pregnancy?
Did u have any complications during pregnancy? Delivery? Or after delivery?
Was you pregnancy full term? Or preterm? Or delayed?
Was it a NVD or CS?
(After birth)-Did the baby cry after birth?
When did u start breast feeding?
When did he pass his/her first stool?
When did he pass his first urine?
Did he have any medical problems after birth?
I-are all your childs immunizations/shots upto date?
I-does he have any ill contacts?
D-is your childs devpt(growth and height) in par with the children of same age?

42

Do you send him to daycare?

When was his last doctors visit? If yes, may I know the reason?
E-ask for activities qs
R-ask for any rash
S-how is his sleep?
FH:
Are there any smokers around the child?
Is the child safe at home? (child safety qs)- break the confidentiality and involve the child
safety team
Closure and advice:
Ms.X, from the information you have given me, I am concerned that your childs fever maybe
due to infection in his upper airways or lungs or bowel (acc to scenario). However, it is very hard
for me to assess her over the telephone and I dont want to jeopardize her health in anyway.I
would like you to bring in your daughter/son to the medical center for a physical examination and
a full assessment. We will then proceed accordingly and at that time I will be in a better position
to tell you what exactly is going on with your child.
Meanwhile, please look for the warning signs like- fever >102F, shaky mvts of his body,
decreased urination, color changes in urine, bluish discoloration of the body.
Advice:
Do continous sponging
Feed your child
Give plenty of fluids like pedialite (if diarrhea), which can correct her dehydration to a certain
extent.
Bring him/her to the hospital ASAP
I hope you understood what we have discussed so far today.
Do you have any concerns or questions for me Ms.x?
I look forward to see you in the hospital. It was nice talking to you. Have a good day. Bye bye.
Q:Ms.X, is it possible to bring your child to the medical center?
If she says no-ask may I know the reason? If financial reasons, then dont worry Ms.x, we have
a good social support team who will help you out in this regard. Does this sound good to you?
FEVER WITH DIARRHEA
D/D:
Rotavirus
Bacterial diarrhea
Lactose intolerance
Food allergy
Malabsorbption
Intessussception
UTI
Neonatal sepsis

Workup:
Physical examination
Stool for leukocytes, ova, parasites, ph
Rotavirus immunoassay
USG abdomen
CBC, electrolytes
UA and C/S

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FEVER WITH RUNNY NOSE AND INCREASED BREATHING

D/D:
Viral URTI
Pneumonia
Otitis media
Septicemia
Meningitis
Occult bacteremia

Workup:
Physical exam
CBC with DC, electrolytes
Blood for C/S, throat swab C/S
Pneumatic otoscopy
LP with opening pressure and CSF analysis
CXR
U/A, C/S

JAUNDICE
DD:
Early onset <1wkPhysiological jaundice
Breast feeding jaundice
ABO/RH incompatibility
Jaundice of prematurity
Neonatal sepsis(if mother had any infection or any new born inf.)
cephalhematoma
Familial neonatal hyperbilirubinemia

Workup:
Physical examination
CBC, ESR, eleclyts,HB
S total bil, DB and IDB
Blood group and typing
Direct coombs test
Blood for C/S, CRP

Late onset >1wkBreast milk jaundice

Metabolic causes-hypothyroidism, galactosemia
C/O discoloration
DOPE
Color changes:
When did you first notice it? <24 hours or >7 days or >14 days of age
What parts of the body turned yellow? Acc to the answer, ask whether skin and eyes both turned
yellow?
Urine:
What is the color of his urine?
How often does he pass urine?
How many diapers do u change per day?
Does he cry while passing urine?
Stools:
What is the color of his stool?
How often does he pass stools?
Did u notice any blood or worms in stool?
What is the consistency of his stool?
Vomitus:
Did he throw up?

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Did u notice any belly distension?

Breast feeding:
Are u breast feeding the child?
When did you first breast feed your child?
How often do you breast feed your child?
How long do you breast feed each time?
Is he sucking well?
Is he also bottle fed? If yes, do you give formula milk or cows milk?
ABO incompatibility:
What is your blood group? Your husbands? Your childs?
Did you become pregnant before? Did you have any miscarriages?
Dehydration:
Did u notice any dry mouth or dry skin?
Did u notice any sunken eyes?
Did u notice any sunken soft head on his head?
How is his skin turgor? Is it moist or dry?
Activities:
Can u tell me more about his activities?
Does he look active and playful/dull and lethargic/irritable?
If dull, is he awake and responsive?
Fever:
Does he have any fever? Any shaky mvts of his body? (kernicterus)
Did you notice any rash on his body?
ROS:
Does he have any runny nose? Cough? Fast breathing?
Did you notice any ear discharge? Ear pulling? Watering from eyes?
PAM H U G S
A F S F-activity, feeding, sucking, family
Family-how many siblings does little x have? How are they doing? Do you send your children to
daycare?
TBIIDERS
T-did he travel anywhere recently? Was your child ever injured?
B-birth history:Now I would like to ask you few qs regarding little johns birth.Is that ok with u?
(During pregnancy)-did u smoke? Drink alcohol? Use ilicit drugs during pregnancy?
Did u have routine checkups during pregnancy? How often?
Did you take MVT supplements and vaccine shots during pregnancy?
Did u have any complications during pregnancy? Delivery? Or after delivery?
Was you pregnancy full term? Or preterm? Or delayed?
Was it a NVD or CS?
(After birth)-Did the baby cry after birth?

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When did u start breast feeding?

When did he pass his/her first stool?
When did he pass his first urine?
Did he have any medical problems after birth?
I-are all your childs immunizations/shots upto date?
I-does he have any ill contacts?
D-is your childs devpt(growth and height) in par with the children of same age?
Do you send him to daycare?
When was his last doctors visit? If yes, may I know the reason?
Closure and advice:
Thankyou for answering all the qs patiently. Now I would like to summarize what you have told
me.
After summary-ask is that all or do you want me to add anything to this?
Now I would like to give my impression:
Based on the information give by you, I think your childs problem could be due to physiological
jaundice, which is a natural condition seen in infants and gradually disappears by 1 to 2 wks.
However, there are also other possibilities like jaundice due to breast feeding or blood group
mismatch or birth defects or some other pathological conditions which needs to be ruled out.
However, it is very hard for me to assess her over the telephone and I dont want to jeopardize
her health in anyway. I would like you to bring in your daughter/son to the medical center for a
physical examination and a full assessment. We will then proceed accordingly and at that time I
will be in a better position to tell you what exactly is going on with your child.
Meanwhile, please look for the warning signs like- fever >102F, shaky mvts of his body,
decreased urination, color changes in urine, bluish discoloration of the body.
Also, I suggest you to feed your baby every 1 to 2 hours during the day and every 4 fours during
the night.
I hope you understood what we have discussed so far today.
Do you have any concerns or questions for me Ms.x.
I look forward to see you in the hospital. It was nice talking to you. Have a good day. Bye bye.
CQ: can this jaundice hurt my baby?
I can understand your apprehension Ms.x. Newborns can develop a mild jaundice after birth and
this type of jaundice will generally resolve but rarely it poses a threat to the baby. If a new born
has a more severe type of jaundice, it may damage his brain. In order to give you a better idea of
the severity of the childs illness, I must examine him and need to run down some blood tests.
After the results are out, I will be in a better position to address your concern.

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STRIDOR
DD: code FCLEAR
Foreign body obstruction
Croup
Laryngitis, laryngomalacia
Epiglottitis
Angioedema
Retropharyngeal abscess
Workup:
Physical exam
ABG analysis
CBC
Xray neck(AP and lateral)
CXR (PA view in expiration)
Direct laryngoscopy and bronchoscopy
Child in ER:
I am really very sorry that your child is in ER. I can understand that you are very anxious about
your childs health, but donot worry, your child is in safe hands. We have a very good intensive
care team at our hospital who will take care of your child very well. Your emotional stability is
very important for your childs health, please be strong.
To know more about your childs problem, I would like to ask you few qs and write down notes
while we talk. I assure you that I will be as quick as possible. So please bear with me for some
time. As soon as I am done with my qs, I will go and examine your child personally. Is that ok
with you? Shall I proceed?
Ok Ms.X, I am Dr.Ravi the attending pediatrician at this medical center and I will be taking care
of your child today
What is your childs name? how old is he/she?
May I know why is he in the ICU?
Mother gives complaint..
Show empathy..
Can you tell me more about your childs problem?
D O P E F AA
E-what was he doing when it started?
F-is the sound consistently there or does it come and go?
Associated qs:
Code BIGDCH
B-when is it better heard? While breathing in or out? Is there any breathlessness? Any bluish
discoloration?
I-did you intervene in any way? Any h/o intubation?
G-guraka-does he snore while sleeping?
D-any drooling or difficulty in swallowing?
C-any cry or cough?
H-any hoarseness?

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Ask for TBIDDERS:

Birth, immunization, diet, daycare, development, doctor visit
Ask for any rash and swelling of face-(hereditary angioedema)
Closure and advice:
If its a phone case-Ms.x, according to the information given by you, I am considering a
possibility of foreign body aspiration. However, there are several other possibilities that need to
be ruled out and I feel that she needs emergency medical attention. So I suggest you to call 911
immediately and bring her to the medical center.
Meanwhile, I advice you not to attempt to remove the foreign body because this may cause it to
become more deeply lodged, if it is actually present.
In case, if you notice any choking or respiratory compromise, please perform a heimlichs
maneuver by thrusting tummy with sudden pressure.

PICKY EATER
DD:
Habitual eating disorder
Low fiber diet
Lead poisioning
Iron deficiency anemia
Parasitic infestation
Hypothyroidism
Opposition defiant disorder
ADHD
Workup:
Physical exam
CBC, serum electrolytes
Serum lead levels
Stool for ova and parasites
Serum TSH
Serum iron studies
Hello, I am Dr.Ravi. I am the attending pediatrician a this medical center. May I know with whom
I am talking to?
What is your relationship with the child?
Its nice to talk to you. How can I help you?
She gives the complaints..
I am sorry to hear that Ms.x. I will try my best to help you out in this regard..
What is your childs name? How old is he?
Where is he? What is he doing now?
Why do you think he is a picky eater?
Does he have any specific preferences for the food?

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D O P E F since how long has he been having this problem? How it is progressing?(is it getting
worse or getting better?) does he constantly behave like that? how frequently does he eat?
Behavior:
Have you ever punished or rewarded your child to alter his eating behavior?
Does he watch tv while eating?
Does he follow his schedule of meals?
Does he often drink high calorie drinks like sodas, juice or milk?
Do you offer any desserts with regular meals?
Bowels:
Does he have any belly pain?
Any problems with bowel mvts? If yes, how many times a week does he have his bowel mvts? (if
<3 stools per week=constipation. If for >2m=chronic constipation)
How are the stools? What is the caliber of the stool?
Have you noticed any blood in the stools? If yes, is it fresh blood or blood mixed with stools?
Does he strain while passing stools?
Toilet training:
When did he start sitting on the toilet?(normal=3yrs)
How long does he sit on the toilet?
Does he resist toilet training?
Does he avoid toilet because of activities such as playing?
Family:
How many children do you have?
How much time do you spend with them?
Who takes care of them when you are working?
Does he go to daycare? If yes, does he have any ill contacts there?
Ask for any other associated symps: URTI, diarrhea symps
Lead poisioning- what kind of house do you live in?(very old one?)
Temper tantrum vs. ADHD:
Is the child easily distractable?
Does he have any difficulty with conc and focus?
How is his memory?
Does he have any problems organizing ideas and belongings?
Does he show any impulsity?
Does he have weak planning and execution?
TBIIDERS
PAM H U G S F
Closure and advice:
Mrs.X, According to the information you provided me, I feel that your son is probably passing
through a normal phase of growth. It is a common problem in this age group. Fortunately, it
responds well to a few behavioral changes.
First of all, I would suggest you to strictly follow a set schedule and offer him variety of foods at
meal time.

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Discourage high calorie drinks b/w meals

Next important thing is environment at meal time. It should be pleasant without any distractions.
Any argument or watching tv should be avoided at the same time.
Regarding the constipation, I would suggest you to provide him high fiber diet like cereals and
vegetables. Encourage him to follow a scheduled time to sit on the toilet by rewarding him.
However, I need to examine him personally and run down some tests to rule out some other
possible causes of constipation and behavioral disorders before I make a definitive diagnosis and
give you my opinion.
Does that sound good to you?
I hope you understand what we discussed today.
Do you have any questions for me?
Ok then, I will be looking forward to see you at the hospital. Take care and bye bye.
ENEURESIS

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