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** Important Notice; this exam is meant to be for 4th year Medical Student, cases will be clear and straightforward**

** YOU ONLY NEED TO ASK 25-35% OF THE QUESTIONS IN THIS HANDOUT, never forget that you are a physician! **

HPI
PMH (you may start with PMH in some patients, or you can leave it after ROS)
After the chief complaint, TRY TO MAKE TIMELINE FOR THE EVENTS, then use any mnemonic, consider your DDx while asking
SIQORR AAA (pronounced sicker AAA, especially for the pain e.g.Abd pain, chest pain, LBP, headache..ect)
S: Site I: Intensity Q: Quality O: Onset & duration (sudden or gradual, freq, setting, progression) R: Radiation, Relation to food
Aggravating (e.g. food, position, activity) Alleviating (e.g. Meds) Ass Sx
DO QPP AAAA (for other symptoms usually, e.g.vomting, diarhheaect)
Duration, Onset, Quality, Progression, Previous (similar episodes), Attribution (trigger?), Aggravating, Alleviating, Ass Sx

ROS (in real exam, try to review constitional, system involved, and very fast screening! You dont need to ask all Qs)
Constitional: WATF!, Weight change, Appetite, Tired (fatigue) & Thirst, Fever & sweating (or night sweating) w or w/o chills,
Heat or cold intolerance, , bleeding tendency, skin rash or easy bruising
HEENT: Headache, facial pain, eye (double or blurry vision, discharge, photophobia), Ears (hearing loss, pain, discharge,
ringing), Nose (discharge, nosebleed, obstruction), throat pain or soreness, neck swelling or pain, change of smell, bleeding gum
CV: Chest pain (or heaviness ), SOB, PND, Orthopnea (number of pillows), palpitation, dizziness or syncope, leg swelling,
extremities (color, cold, pain, hair loss or ulcers), walking distance (for SOB or limb pain), fatigue, varicose veins, dental decay
RS: SOB, Cough, sputum, hemoptysis, hoarseness, wheezing, chest pain, exercise tolerance, snoring
GI: N,V,D (freq, or consistency), hematemesis, C, Abdominal pain or distension, heartburn, dysphagia, regurgitation, flatulence,
prolapse, incontinence, tenesms, jaundice, pruritus, stool change (melena, mucus or rectal bleeding, pale stool), mouth dryness
or ulcers
MS: Muscle or joint pain, swelling, limitation of joint movement, disturbances of gait, morning stiffness, deformities, joint
instability, back pain, photosensitivity
Hema: fatigue, SOB, bleeding (menstrual or GI), bruising, LN enlargement
Neuro: LOC, fits (seizures -> tongue biting? Urine or stool incontinence?), aura, dizziness, muscle weakness, abnormal
sensations (numbness, tingling or lost sensation), memory loss, concentration, tremor or involuntary movement, speech or
swallowing difficulties, walking, sphincter control
Psychiatry: OHHH I,m SSAD because my Terrible GMC car doesnt take us to Job and family/social events! (O: odd beliefs,
Hope, Hallucinations (visual or auditory), Hurting other, Interest, Mood, Sleep (too much, daytime or little), Suicide {thought?
Plan?}, Appetite and Anxiety and weight, Defect in motor activity {restless or slowed down}, Tired, Traumatic event, Thinking
others may hurt you (paranoid), Energy, Guilty, Memory, Concentration, impact on job/family/social life
GU: dysuria, loin pain, freq of micturition (polyuria, nocturia, anuria), change in stream (decrease in stream size, dribbling),
retention, hesitancy, urgency, thirst, hematuria, incontinence, discharge, hernias, infertility, genital rash or ulcers, erectile
dysfunction
Birth/developmental: [child]: Full term? Premature? CS or NVSD? Developmental milestones (in comparison with other
children)?

PAM HITS FOGSS


P: PMH [when? Last check up? Results?], and PSH)
A: Allergy (NKDA)
M: Meds (OCPs, OTC, prescriptions, vitamins or herbs) {Name? Why? For how long? Complaint? SE?}
F: FH (similar symptoms in the family, illnesses in the family)
O: GPA (if the case is not OB/GYN related, just ask about the LMP and its regularity? Any heavy bleeding?)
G: menarche, menopause, freq & duration of periods, heavy bleeding (pads or tampons/day, N.B: the average of total number is
12/period), spotting between periods, regularity, vaginal discharge or dryness, itching, dysmenorrhea, dyspareunia, prolapse,
breast (pain, discharges, lumps or skin changes), Pap smear, vaginal or CS, gestational DM or HTN {preeclampsia}
S: sexual history: active? Number of partners in last 6 m? M/F or both? Birth controls (e.g. Condoms)? Tested for HIV? Hx of
STDs?
S:Social history: WWAANTTED (you are Socially wwaanted!): S: stress? W:Work, W:Weight, A: At home (lives with whom?),
A:Alchole drinking (if > 2 daily for M or > 1 for F ask CAGE), N:Nasty drugs (recreational or street drugs), T: tobacco products
(e.g. cigars, chewing, or {smoking pack years = Number of Packs per day (PPD) X number of years}), T:Travel, Tick bites ,
E:Exercise, E: Eating habits & D:Diet
*** In the real exam, just do the system involved, make your exam more DDx based, you dont have time for full exam***
VS: 120/80, p 110, RR 18, afebrile (you can write WNL)
GA: NAD (no acute distress) or in [mild/moderate/severe] distress [pain/SOB], A&O x 3
HEENT: (do it if complaining of: headache, head trauma, visual disturbance, eye pain, tinnitus, vertigo, hearing loss, rhinorrhea,
epistaxis, sinus pain, pharyngitis, voice changes, jaw pain or fatigue)
Head: NCAT, (-) scars, rashes, lumps, hair loss, facial asymmetry, involuntary movements, edema, sinus tenderness.
Eyes: EOMI, PERRLA (Equal; Round; Reactive to; Light and; Accommodation), No Nystagmus, fundoscopy (red reflex, no
papilledema or exudates), no visual field defects, VA: 20/20 OU [both eyes] (Snellen eye chart), conjunctiva (pale, redness).
Ears: ear canals w/o abnormalities, TM w/o erythema or effusion. Hearing grossly intact BL, NL Weber and Rinne [or Weber
midline, Rinne with AC > BC) (do them if screen hearing test is Abn)
Nose: nasal turbinates not congested, no discharge, no septal deviation/perforation, no polyp
Mouth: no tonsillar enlargement, vesicles, ulcers, dentition NL. No cyanosis
Throat: No erythema or exudates, uvula midline
Neck: NL ROM, (-) tenderness, bruit, LAD, salivary glands enlargement, thyroid enlargement, lhermitte's sign, spurlings test

CNS (if complaining of CVA symptoms, headache, dizziness, weakness, abn sensation, peripheral neuropathy e.g.DM)
MMS: A&Ox3, concentration (world reversely), memory (breakfast? DOB?) are NL, following commands
CNs are intact except (),
Motor: 5/5 UE & LE B/L, NL tone. Sensation: sharp/dull/vibration/position senses are intact B/L
DTR: 2/4 B/L (biceps, tricps, brachioradialis, patellar, achilles) & Babinski sign (down going toes B/L or up going).
Cerebellar: coordination intact (F to N, heel to shin or alternating movements) / gait NL. Romberg sign (- or +)
Special signs: Kernig or Brudzinki (- or +), No stiff neck (Neck is supple), straight leg raising (- or +)

Chest (if complaining of Cough, SOB, wheezing, chest pain or URTI, stridor, hoarseness, palpitation, pedal edam or LOC)
Insp: A/P diameter NL, no deformities, symmetrical chest movement, no scars, no paradoxical abd movement
Palp: Lungs: TVF symmetrical B/L (not increa or decrea), - tenderness, lung expansion symmetrical B/L, NL diaphragmatic
excursion,
Heart: PMI not displaced, no heave or thrills
Percussion: resonant and equal B/L (never percuss or auscultate on scapula!)
Auscultation: Lungs: CTA B/L (vesicular): - rales/wheezes/rhonchi, (-) bronchophony & whispered bronchophony [with 99],
egophony NL
Heart: S1 & S2 are NL, NL splitting (-) MRG (murmur, rubs, gallops) (in 3 positions: sitting, lying, lateral decubitus)
Neck: (-) JVD, carotid bruit and carotid pulse, heart murmur radiation to neck, no tracheal deviation or accessory use
Extremities: peripheral pulses intact [2+] (RRR; Regular Rate & Rhythm), (-) ankle swelling, (-) cyanosis & clubbing or nail
changes, flapping tremor, palmar erythema

ABD (if complaining Abdominal pain, diarrhoea, constipation, vomiting, hematochezia, jaundice, UTI symptoms, haematuria,
pelvic pain, pregnancy, abnormal vaginal bleeding, sexual dysfunction and hematemesis)
Insp: normal appearance, (-) scars, swelling, rashes, bruises, visible veins, ND, peristalsis, straie
Auscultation (first!): NL active BS in 4Q (not hyper- or hypoactive), (-) Abd bruit (aortic, renal or iliac arteries)
Palpation: S [Soft] (no guarding or rigidity), NT, no HSM [liver span is 10 cm in MCL], no mass and no CVAT
Percussion: tympanic in 4Q [not dull or high tympani] Special signs: (-) Murphys, Rebound, Rovsing, Psoas, Obturator
Musculoskeletal (if complaining of Joint pain, extremity pain, injury, decreased ROM, weakness, fatigue, any rheumatology case)
Areas are: Neck/shoulder, elbow, wrist/hand, ankle/feet
Insp: erythema, swelling, deformities & asymmetry, signs of trauma, involuntary movements, atrophy, rash, scars
Palpate: Warmth or tenderness, stable joints, no crepitus [No Abnormalities in spine or paraspinal tenderness]
* Active and Passive ROM (you can say NL ROM) * Gait * phalen test (or Tinels sign)
* Limited neurological & vascular examination of the affected area
Psychiatric Mental Status Exam (this one is not that important, you can ignore it!)
GA: not in distressed and well groomed (Abn e.g.dirty torn clothes, smells of beer, quiet, restless, not making eye contact)
MMS: A&Ox3, concentration (world reversely) and memory (e.g DOB? Repeating 3 stuff?) are NL.
Speech: fluid and goal directed (if Abn Slow, rapid, pressured, incoherent)
Mood (emotions precived): Euthymic (if Abn sad, angry, anxious, depressed or happy)
Affect (emotions responses): (labile, flat, blunted)
Abnormal perception: hallucination (auditory [psychotic], visual [organic], tactile [cocine, alcho withdral], olfact [seizure]), illusion (sensory
misperceptions)
Thoughts: * Form of thoughts: flight of ideas, loose associations, tangentially, circumstantiality)
* Content: delusions, paranoia, suicidal/ homicidal ideation or plan
Judgment/insight: (what you gonna do if you find a self-addressed envelope in street?): intact
Doorway information
Write name,age, F/M, CC, vitals, make 1ry DDx

Knock, introduce (Hello Mr.John, good morning, Im Dr.Abdurhaman [you can shake hands], Im gonna be your
doctor today, How would you like to be addressed? Im gonna drape you first to make sure you are comfortable,
do you mind if you have a seat? Ill ask you few questions and conduct a physical examination on you, They told
youve come with Belly pain, can you please tell more about it? I gonna take some notes as we speak)..complete
the focused Hx

Alright Mr. John, if you excuse me, Im gonna conduct a physical examination on you, Ill wash my hands first

Wash your hands (you can ask while washing: Mr. John, can you tell me the impact of this problem on your usual
life? Do you have any idea whats going on with you? Do you have Support system at home?)

Do focused PE

Closure
* Alright Mr./Ms.___, thank you for your cooperation, now I would like to sit down and discuss what I think so
far. First, I promise you I will be beside you till we get this over. Secondly, let me summarize what you have told
me, you told me that: _ and _, Is that right? On the physical exam I noted __. With all the information you told
me and what I noted on the physical exam, I am considering a couple of possibilities, it may be:__ or ___ (give
2ry DDx), I need to run some tests (explain them) to find out exactly whats going on.
* As soon as I get the results, we can meet again to go over everything. At that time, Ill explain the details and
we will talk about your options for treatment, does this sound OK? Do you have any Qs or concerns you would
like to ask before I go? Do you understand what Ive just said? Do you agree to the plan?
* Ok then, Im glad that I was able to work with you, We will try to make you feel better, thanks for your cooperation and
have a good day (OR; now Ill leave, my nurse will come to take the blood work, Ill see after that)

Counsel
If the SP smokes, drinking problem, eats fatty food, does not exercise, uses
recreational drugs, has multiple sexual partners, does not use condoms,
trichomonosis, chronic conditions (e.g.HTN or DM) ; you can say: Mr.John, I have
notice that you _. Are you willing to quit? If you need any more help from me, just
let me know, Ill be glad to help

Investigations: MS Resp Endocrine


* CBC with Diff * CBC with Diff, ESR * CBC with Diff, ESR
HEENT * X-ray * Chest X-ray * Blood sugar
* X-ray, CT, MRI of the head * Joint Aspiration for * Sputum studies (Culture and * Serum Electolytes
* Complete Audiometry and culture/sensitivity, senitivity, G-stain, AFB) * Serum Ca
ympanometry cytology, crystals * PFT and spiromety * Thyroid scan T3/T4/TSH
* CBC with Diff, ESR, * RF, HLA-B27 * PPD * 24h Uniranry
Cluture/Sensitivity for any * Serum UA * ABG and pulse oximetry catecholamiens and
dischareg * ANA, anti-dsDNA ABD metabolites
* Muscle biopsy * Rectal examination * Urine for Ketons and
CNS * CBC with Diff, ESR Sugar
* CBC with Diff CVS * Abd X-ray
* X-ray, CT, MRI * EKG and * US of Abd Psychiatry
* LP eochoardiogram * LFTs (AST, ALT, GGT), Amylase, lipase * CBC with Diff, ESR
* Carotid Dopplar Sudy * Cardiac Enzymes * CT abd/pelvis * CT and MRI of brain
* EEG (CPK-MB, Troponin, LDH) * Upper GI series- Barium swallo, * Thyroid scan T3/T4/TSH
* Electromyography and * Chest X-ray endoscopy, ERCP * Serum Electolytes
Nerve conduction studies * Lipid profile * Lower GI series enema, colonscopy * Urine analysis
* Echocardigram for * Thyroid scan * FOB * Drug screen/HIV
suspected PE * Serum electolytes * RFT

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