Please note that this is only a draft version based on Dr Sherry's’s lectures. Edited and organized for the sake of all attendances of the Canadian Osce Exams: NAC OSCE and MCCQE2.
 
Ocp Counselling
21 F for OCPs Counsel x 10 min
Good morning xxx,I’m Dr...... As I understand,you’re here today because you want a prescription for Birth Control pills.During the next few minutes, if you dont mind ,I will ask some questions

Questions here:
1.Have you ever used any form of contraception before ?
2.Why do you want to use it?
2.1.If in stable relationship
2.2.If sexually active
2.3.Do you practise safe sex?
2.4.How do you feel about this relationship?
2.5.Prior to this were you in any other relationship?
2.6.Whose idea was it/ Yours or His?
MGOS
MENSES:
MENSES Use the word ―period‖
1. When was your last period?
2. Are your periods regular / not
3.How often?
4.How many days or How long does it last?
5.How many pads do you use/change?
6.Are the pads full?
7.Are they heavy?
8.Do you see clots?
9.Between periods do you have spotting?
10.From your last menstrual period was your period different from the current one?
11.At what age did you start your periods?
12.Were they regular/irregular?
13.When did it become regular?
14.Are your periods painful / painless?
15.If irregular from beginning?
16.Discharge – ask if pregnant and when LMP
GYENECOLOGY
1.Any history of Gyn. Disease – polyps or cysts
2. History of pelvic surgery (if yes – when?)
3.Have you used any birth control?
4.When/type/any complications
5.Pap’s smear
OBSTETRICS:
Have you ever been pregnant?
Have you ever had an abortion or miscarriage?
SEXUAL HISTORY:
Any STDs?
Any PIDs?
Any partner with STD?
CONTRAINDICATIONS:
To find out if you’re a suitable candidate,I need to ask a few more
questions: ABCD (Active liver disease, Bleeding, Cancer, DVT) 1. Any abnormal vaginal bleeding?
2.Any active liver disease: (Ac & Ch)
3.CVS:Have you ever had clots in your calves/DVT/Very High blood pressure
4.H/o Migraine headaches
5.FH of Ca breast/Uterine or Liver
AGREE to give if No CI
EXPLAIN what are OCs
1.Combination of hormones Estrogen & Progesterone or sometimes only a progesterone
2.These come in packs of 21 or 28 pills
3.They prevent pregnancy by interfering with hormone signals in our body & prevent ovulation
4.Also make the inner lining of the womb & makes it hostile for conception
5.Thickens secretions at the mouth of the uterus & prevents conception
MISSED PILL;
To be taken at same time every day, so chances of forgetting is less & constant blood levels
1St pill on 1st Sunday of period, or 1st day of periods
1st month use back up method of Cx like a condom
In first 2 weeks:
If miss one pill: Take 2 pills next day & use condom x 1 week
If miss 2 pills: Take 2 pills same day + 2 pills day after + Condom x 7 days
If miss 3 pills: Stop,use condom & restart new pack In 3rd week:
If you miss any pills restart new pack
Explain BENEFITS:
1.Help regulate cycle if periods are irregular
2.Will eliminate pain
3.Less blood loss during periods
4.Less chances of benign breast disease & ovarian Ca
But like any other medications, there are also the SIDE EFFECTS:
•MILD
N/V,Wt gain (5lbs)breast heaviness,mood changes,Spotting may occur in the initial months If these occur,you can change brand
•SEVERE;
Severe Ha/SOB Chest pain -----> If these occur STOP the pill & sek urgent medical attention DRUG INTERACTIONS:
If takes any other medications,let her Dr know she s on the pill
SAFE Sex:
PAP’s Smear
If Teenager:HEAADDS
Last any Concerns or qns?

ABORTION

1.Young woman 19 yrs asking for abortion x 10 mins counsel

2.Can be a teenager with a vague complain

a.Read body language & assure Confidentiality

b.When did sexual contact occur?

c.Who was the partner?

d.Was she raped or was it against her will?

e.Is she being regularly abused?

f.Do her parents know?

M (Signs of pregnancy: engorgement of breast, urine frequency, n&v)

O

G

S

PMH

SHx:

HEADDSSS:

Home enviorenment & parental attitude

MOOD & Interest SUICIDAL IDEATION NOW?

When pt tells outright she wants an abortion:

How do you feel about having an abortion?

If she says she feels there is no other option:

Explain that there are other options, Do you want to know them?

When did she find out she was pregnant?

Here be sensitive if she found out last night, she is probably in a panic, but if she has known it

for a week, she has thought about it well, & is more decisive.

Before it can be done, I need to ask you some qns

1.How did she find out she was pregnant?

2.Was she using any contraception?

3.Has she spoken to her partner/family/friend?

4.Would she like to talk about it?

LMP: How was her LMP, was it similar to her previous LMP? Or was it shorter, lighter?

Is there Nx/V,visiting washroom more frequently?

Breast engorgement?

O

Have you been pregnant before?

Have you ever had an abortion/miscarriage?

G

Has she ever used any kind of birth control before?

Any Pelvic surgeries

Any Pap smear (depending on age)

H/O STIs

Since it is the first time I’m seeing you, I need to ask about

PMH;

Any H/o HTN/Liver disease/DM?

Surgeries/Anaesthesia complications

Blood Group

Any Medications/Allergies

SOCIAL Hx:

With whom do you live?

How do you support yourself financially?

If young teen: HEAADDS

Whatever you choose to decide, I will support you. Is she decides to go in for an abortion:

I will refer you to an abortion clinic

However it is difficult to get an obstetrician who will do it after 20 weeks

She has to make a decision fast

Also here ask about her own support system (family/boyfriend)

I will also get you connected with a support group, who are women who’ve had abortions before & will help you cope with it.

Now in addition to abortion there are OTHER OPTIONS:

Would you like me to tell you about them?

1.If your concern is financial, you can carry on this pregnancy & there are a lot of support groups as well as the government who will help you.

2.You can carry on this pregnancy & give up the baby for adoption, a lot of people are looking for a child also nowadays you can have visitation rights in certain cases.

If Pt is still going for an abortion:

For now, I will do

1.PAPs test

2.Blood tests: Sr B HCG & Blood group & Rh typing

3.Ultra Sound

Once your pregnancy has been confirmed by us, I will send you to the abortion clinic From now, until the time you’ve the abortion, you’ve to;

Quit Smoking/Alcohol/Drugs

If you happen to see any dr during this time period, you’ve to inform him you’re pregnant

OBESITY COUNSELLING

38 YOM 6 ft height,weight=260Ib 10 min.HX. and Education Keys:

•Explore motivations for wt.loss.

•Provide information about the consequences of obesity (health and psychological wellbeing) and nutrition.

•Set realistic goals, target BMI

•Offer support/reinforcement throughout the weight-losing process. Hx

DIET & EXERCISE:

Motivation for losing wt. now?

Self –image,

Health concerns? ……… Can you tell me more. Good decision to come today, I am glad you came.

If patient request first surgery, tell him that sound reasonable however, surgery is not the first line can be done based on BMI if >40 If you like I can calculate it for you; kg/m2.

I need information about your condition:

WEIGHT:

1.What is your weight today?

2.Highest weight.

3.When started to gain wt?

4.When started to be concerned?

5.Have you tried any wt- loss programs?

6.Which one?

7.How long?

8.Did you lose wt?

9.Why did you stop?

I am going to ask you Qs to see

WHY YOU’RE GAINING WEIGHT:

Do you calculate your calorie intake?

How many meals do you take/day including snacks?

Tell me more about your DIET:

•What do you eat?

•How much fat, fruit, veg bread?

Eat while watching TV,

Before bed,

Breakfast daily,

Ever eat to relax or when stressed?

Binge eating?

Do you feel guilty about your eating?

Do you induce vomiting/purging?

ALCOHOL

How about your ACTIVITY, Do

you exercise? IMPACT:

I am going to ask you how this Affects your life?

1.Difficulty sleeping,

2.Tiredness,

3.Heart burn,

4.Nausea, vomiting,

5.GB stones, bowel motion,

6. Back pain,

7. Jt pain.

PMH: HTN, DM,

Medications: anti-psychotic, OTC, steroids, thyroid disease, OCP.

Social Hx: With whom do you live? Any change in sexual desire?

How it affects your self esteem,mood and interest?

Do you smoke? Drink? Recreational drugs?

FHx : obesity Education:

There are some genetic factors that influence wt. We can’t modify these but we can modify our diet and exercise. In some people, diseases are the underlying cause for obesity.

Give patient their ideal wt. for ht. >20% ideal wt is obesity.

Being overwt increases the risk of

Hypertension,CVD,CAD,GB disease,DM,fatty liver,cancers(breast,bowel),OA,sleep apnea,spinal dysfunction.

• We recommend to lose 10% of your body wt.over 6 months (gradually).guidance is BMI

There are 2 methods to lose wt: Decrease intake or Exercising more.

If you like I can refer you to a dietician.

We also recommend dividing your meals into 3 small and in between snacks ( carrot, veg.or fruit) 55% CHO, 15% protein,30% fat Avoid saturated fat, cheese, alcohol Give patient a target caloric intake: to lose 1 Ib/week,should take 300-500 kcal less 1g fat-9kcal, 1g CHO-4kcal, 1g protein-4kcal

Do not recommend diet medications and fad diet, these may be harmful and are of no long-term benefit. If BMI>27 + RF (DM, Htn...) or BMI > 30 start pharmacotherapy:

Xenical=increase bulk of stools, leakage, decrease absorption of fat sol.Vit.

Meridia (sibutramine) = suppress appetite, cause heart racing, hypertension.

IF BMI>35 + RF or BMI > 40 recommend Baratric srgery

Exercise:begin with walking,regularly 30 min,4-5 times per week

Reach 60-80% maximum heart rate (220-age)

Self-monitoring, group support

Follow-up: advise patient to come back in a week with food intake diary
 
70 yr old female with H/o fall at home .Brought in by ambulance personell to the ER. She is medicaly cleared; In the next 20 minutes take history & Counsel;
 
Diff/Diag (Dd):
1.Poly pharmacy
2. Recent hypovolemeia •Diarrhea/Vomiting •Lack of intake •Recent bleeding
3.Orthostatic hypotension
4.Hypoglycemia
5.Elder abuse FALL: 1.When did the fall occur? 2.Where did it occur? 3.Were you alone?
4.Could you get up by yourself or did you need help?
5.How long before you got help?
6.Did you trip or just feel your legs give way?
7.If there was a witness around ask permission to speak to witness after you finish talking to Pt to obtain collateral history
3 parts of history relating to the EVENT:
A.Before fall
B.During the Fall
C.After the fall
Events assoc with the Fall: A.Before:

1.Did you feel

2.Light headed/ Spinning/ Hungry/ Heart racing & Sweating --- HYPOGLYCEMIA

3.Chest pain/ Palpitations/ Shortness of breath----CVS

4.Lights flashing/ Strange smell/ Strange feeling in body--Seizure

5.Weakness/Numbness/Dificulty finding words/Visual disturbances --CNS/STROKE

6.Was the lighting good?

7.How is your vision

8.Is your footwear comfortable?

B.During the Fall:

1.Did your wife mention that you were shaking or making jerky movts?

2.Did you wet yourself?

3.Turn blue & were stiff?

4.Bite your tongue?

C.After the fall:

1.Nausea/Vomiting

2.Weaknes

3.Difficulty finding words

4.Any vision difficulties

5.Loss of sensation in the arms or legs

6.Ringing in ears

Has this ever happened before

1.When & where

2.Did you seek medical help then

3.What were you advised?

CONSTITUTIONAL SYMPTOMS:

•Fever & Chills & Night sweats

•Wt loss & Loss of appetite

•Lumps & Bumps

Sx related to CVS:

Chest pain/SOB/Palpitations

Sx of CNS:

Weakness/Numbness/Loss of vision/LOC

Past Medical History;

1.Are you taking any medications?

2.Can you take them by yourself or does your caregiver give them to you?

3.Do you take them regularly as prescribed?

4.Can I see them please?

Please see the meds

Was there a recent change in the meds

5.Besides these do you take any additional OTC products or herbal medications?

6.Do you take alcohol? ..............

•How much do you take regularly?

•Did you take alcohol prior to the fall?

7.Do you have high blood pressure? • When was it last checked?

• What did your doctor have to say about it?

8.Do you have high blood sugar or Diabetes? • When was it last checked?

• What did your doctor have to say about it?

9.Did you ever have a stroke or heart attack?

10.Were you ever diagnosed with Cancer

11.Were you hospitalized at any time in your life?

I need to ask a few more questions concerning your lifestyle that will aid me to help you.

It is all confidential & my duty is to help you (When you suspect Elder abuse)

1. With whom do you live?

2.Are you happy living with XXXXX

3.Who prepares your meals?

4.Do you do your own shopping?

5.Do you manage your own finances?

6.Do you go out of the house & meet up with friends & have your own social life?

7.Do you get into arguments with XXXX?

8.Have you ever been hit or yelled at or threatened by XXXX?

COUNSELLING FOR POLYPHARMACY (Orthostatic Hypotension)

Based on what you’ve told me most likely the reason of your fall is a condition called “Orthoststic Hypotension”.Have you ever heard about it?..........

When you change position from lying to sitting or standing blood pools to the legs & Bld vessels narrow to maintain BP.

In pts with OH because of Age,Medications,DM or a combination of these condts body might fail to react,& blood pools in the legs & thus BP drops & there is not enough bld reaching the brain.

There is a possibility that this might happen again & from now on whenever you change your posn from lying get up slowly,sit at edge of bed & slowly get up.

I need to get in touch with your doctor & modify the dosage of your meds or change them. Is it alright with you?

I need to talk now to your wife & do an ECG to check your heart

HA DOMESTIC VIOLENCE

Domestic Violence common presentations:

1.HA

2.Abd Pain

3.Ac Abd

4.Insomnia

5.Sleeping pills

6.Vaginal Bleeding

Sx

1.No good eye contact

2.Vague complaints

3.Non communicative

OCD/PQRST

CONSTITUTIONAL Sx: R/o Migraine & Tension HA RISK FCTS:

Smoke/Alcohol/Recreational drugs

PMH:Are you on any meds/OTC/Herbal meds?

Were you hospitalized at any time?

FH:

SOCIAL HISTORY: Important**

All information you give here is entirely confidential & will not be released unless you authorize it Who lives with you?

Any recent changes/Stress in your relationship SCREEN FOR DOMESTIC VILOENCE:

Does your Partner:

1.Hit you?

2.What happens during an argument?

3.when he is angry,does he :

4.Shout/Swear & call you names or demean you?

5.Has your partner ever ridiculed you or cut you off from other relationships with friends/family?

6.Have you ever sought help from others in health care? ABUSE RISK FCTS:

1.Drink alcohol,drink more now than before?

2.Does he have access to firearms?

3.Does he ever get angry to the point where he gets

physical & hits you?Did you ever have to go to the ER? Was there a serious consequence?

4.Are you having more arguments now

5.Does he get more angry now,& How has all this affected your self esteem?

6.How does it make you feel?

7.Does he ever force you to have sex against your will?

8.Who controls the finances & spending?

9.Has he ever mistreated you in front of the children?

If yes: it is emotional abuseto children & has to be reported to CAS

10.Has he ever misRxed th children?

11.Have you ever thought of putting an end to your life or his life?

Have you spoken to anybody abt this?

Do you have some support?

COUNSELLING: Empowering & Education

3 kinds of Pt:

1.She wants Help

2.She might Consider getting help

3.She does not want to get help & thinks he is right

I’d like you to know that what you’re experiencing is called “Domestic Violence “or Spousal abuse.

It is a crime against the law & not acceptable.

It is not your fault & you should not accept it & feel guilty

It can get out of hand & you can get harmed seriously

Call Police (Never Call Police from your office)

Contact Social worker, who will help you with housing, finding a job & finances & child support If she is considering

Escape Plan

Keep a bag with important documents,change of clothes & hide it

DOCUMENT

Fup x 3 days

 

Diabetic Daughter 2y, Counsel



Either she is not doing well in school

Not seeing well

Not playing well, tired

DKA

Is it regular f/u or something special you wanted to discuss?

When was the last f/u?

How was she diagnosed?

What happen then?

What were the symptoms?

Is there any pain / vomiting?

Are you feeling eating/drinking/peeing more?

Is there any weight loss or blurred vision?

From the last f/u till now have you had DKA? How about before?

Have you had low blood sugar?

Talk with the father: which medication does she take? How does she take? When was the last time?

Do you take insulin or somebody else gave it to you?

Do you take it all the time?

DO you skip dose?

Does she need any help to take insulin?

DO you measure blood sugar regularly?

When was the last time? Do you record them in the machine?

(The glucometer should be used by only one patient).

There is a blood work called ―Hemoglobin A1C‖

it is done every three month – did you do it?

Did you start new medication? How about your diet?

DO you have your log book?

What do you eat?

Have you ever seen by a dietician?

PMHx

FHx

Counseling A lot of people have diabetes and she is not the only one.

What’s your understanding of diabetes?

Whenever we eat food contains sugar it is absorbed in our stomach and goes to the blood and from there to different parts of our body.

Sugar act in our body like a fuel, in order for our body to use this energy it needs insulin.

Patients having diabetes have not enough insulin. Sugar will be built up in your blood. The body tries to get rid or it, by peeing extra sugar – this will lead to thirsty and tiredness. This can be avoided by controlling the blood sugar.

If you control your blood sugar you’ll be able to play again.

If not controlled – may end in DKA, hypoglycaemia and serious consequences.

Always be aware of hypoglycaemic symptoms: loss of conscious, sweating, heart racing, hungry.

Since you might lose conscious it is important to carry MedAlert Caed or Bracelet which will clarify your situation.

Medical Error, Wrong blood transfused

When there is a mistake, always there is a kind of unintentional medical error.

(to the nurse) when informed about wrong blood – ask:

―did you stop the blood?‖ say: ―Well done!‖

If she asks not to tell the patient...ask her what her believe she may loose her job, and it is too early to determine who is responsible.

Errors take place in medical practice. We don’t know what exactly happened.

We will stabilize patient and ensure he’s fine and later deal with this issue.

(to the patient) Intro: I am the doctor in charge, and it looks like it was an unintentional medical error took place. We need to make sure you are stable. We don’t know who is responsible, there are at least 15 steps and in each step could have been an error.

We will fill an incident report and as soon as we get result we will inform you. You can sue, it is your right at the moment it is my priority to stabilize you.

ABCD

A – Open your mouth (check for anaphylaxis, no swelling in mouth, ask for any itchiness, or difficulty breathing), Oxygen saturation.

Normal air entry.

Normal S1, S2

Vitals again

Remove blood unit and keep cannula. Start new IV line.

Once new line, don’t give fluids if stable.

Send blood: CBC, Lytes, INR, PTT, LFT, Cr, BUN, FDP, Haptoglobulin, Direct coombs test; Urinalysis: hemoglobulinuria

Unit to be sent to blood bank for cross matching.

Ask nurse to call the blood bank and keep original blood.

D

D1 – I’d like to shine a light in your eyes. Pupils are round, active, and symmetrical. Squeeze my finger, wriggle...wriggle... D2 – (if febrile) give tylanol Please prepare for me benedril (Diphenhydramine) 50mg. Steroids (Hydrocortisone) and Epinephrine Secondary survey

Hx (two parts:) condition (how is he feeling now) and the other is: ―Why blood was given?‖ Condition: Do you feel warm? Chills? Itchiness? Tinglings? Diffculty breathing? Wheezing? Swelling in lips / fingers? Hives?

Before transfusion did you have fever?

Check for haemolytic reaction – any back or flank pain?

P/E – no oozing at IV line

Then press on flank and back – no pain for haemolytic reaction.

Is it the first time?

Why did you receive blood?

If received blood before – was there any complications?

Any long term diseases?

Counseling

Mr. X what do you know about blood transfusion?

It is a life saving measure, and a lot of measures are taken to make sure it is safe.

However, like any other medication with blood transfusion there could be side effects, and these side effects could be serious.

The most common side effect is febrile reaction (3%), usually it is self limited and can happen again. Next time you receive blood we will give you tylanol.

Anaphylactic reaction. It is a severe allergic reaction, and it is very serious and we cannot predict it. However, we have good measures to deal with it, and your symptoms make it less likely that you have had an anaphylactic reaction. The yhird reaction reaction is more serious and called haemolytic reaction. Usually happens when patients receive blood belonging to another blood group. The fact that this blood is same as your blood group, and the symptoms are not consistent with haemolytic anemia make it less likely that this is not the case here. The blood is sent to the blood bank and once results are back we will get final confirmation, we will able to reassure you.

  Febrile Seizure



A child brought to the ER because of febrile seizure. Next 10m counsel him.

He is stable. During the next few minutes I’ll ask you few questions, and after that I’ll go with you to see him.

You should r/o meningitis. Educate, and what to do next time. Did you see him? (Started to shake. All over his body? Bite his tongue / roling up his etes / wet himself).

After the seizure does he have any neurologic deficits. How long did it last, or did you come on your by his own or medcial staff. Did he stop seizing on his own or after medical interv. Is it the 1st time?

Ask about fever? (if it started a week ago – did you seek medical assistance? Discharge? Did they give you any treatment? Did they give it to him or no?) Why! Some studies show you can treat OM without antibiotics. You should look for the reason not to give the antibiotics (negligence?). Is he having any vomiting? Skin rash? Coughing? Head to toe...

If you find nothing – ask when he got his last shot? (up to 72 hours he can have fever).

R/O meningitis, pneumonia.

Any family history of febrile seizures, epilepsy BINDE (especially immunization).

Counseling:

Your child has condition called febrile seizure (FS).

It is a condition that might happen from 6m to 60m. We don’t know exactly why – we believe it is a sudden change in the temp. This might lead to the seizure. This condition might happen again.

Any time your child has fever – seek medical admition. Give tylanol and sponge to decrease his temp.

Most of the children will outgrow this condition by the 6th year.

They don’t recommend Diazepam because it might make him drowsy.

If it stopped less than 5m or more than 5m including neurological symptoms seek ER immediately. Brochure.

“This is Dr. ... (immediately should introduce yourself). I am the Dr. In charge in the ER. I am calling that your child swallow medication. I know you are stressed, I need to take your phone number and address, and how far it is from the hospital.” Stay calm. Your son needs you, I am going to give you some instructions and you need to follow them. Is your son is alert or not? Is he conscious? Can he talk to you? Can he recognize you? If he doesn’t – do you know how to do CPR and start with that. He’s crying. What is colour? Pink. Hold him and try to calm and sooth him. If he his conscious – try to hold him and check his mouth. Is he breathing? We’ll send the ambulance for you. When did it happen? How long was he alone? Which medications did he take? Do you have the container? (don’t go to the next room to bring them). Do you know what condition your father have (was it vitamins, sleeping pills, or any other?) how much the amount? Don’t use any ippecak?

Is it happened before? What is the weight of the child? BINDE (was it full date, did he needed special attention after term, does he have any special conditions). Weight for two reasons – antidote and estimate neglect.

Post encounter Q: what are the first four steps you do when he arrives? (ABC, Monitor vitals, IV line, NG, Foley as needed, Blood works – CBC, Lytes, BUN, Cr, Osmolality, Coagul, LFTs, Tox screen – blood and urine).

List three risk factors for this child.

What is the antidote for betablocker (glucagon) and for CaChannel is (Calcium gluconate). CAS and Poisoning centre.

Second scenario – while he is seizing just put him on the side, and not start any CPR. Before I proceed I’d like to take your phone number and address. Is it the same time or happened before. If it is the second time – more than 15m he needs intervention. Is he seizing right now? Try to put him on the floor on the left side (the right bronchus is shorter than the lt.). Observe him. What is his colour? Is he still shaking? You send the ambulance. Can you tap on his shoulder? If he is not responding – can you do CPR? Can you feel his pulse? Is he alert? Can he talk to you? Can he move his legs? Was he shaking? Does your child have fever? Did you seek medical attention? What prevented you from giving the medication?



Post Concussion.

2 scenarios (Osgood schlatter and Post-concussion)

Decision will based whether the child can tolerate pain or not?

#1 About to see the father of 14yom with Osgood Schlatter.

Make sure that the child best interest are preserved. What was done to diagnose the child?

OCD PQRST compare to the other knee, is the first time or not, was any trauma. What is the child wish? (Don’t go for HEADDSSS since it is the father).

Counseling

What is your understanding of OS.



Let me explain to you what is the mechanism for OS. Avoid him from playing, especially jumping. But he can continue with ice presses and pain killers. The rule is that he can continue up to his limit of his pain.

54 year old female comes to clinic concerning about using HRT.

. When a patient has concern about any subject, address it very soon. Don't wait to the end.

Dr: As far as I understand you're here as you have concern about using HRT. Patient: yes Dr. I feel I am confused about using HRT. Always ask what do you mean by HRT. So the patient will tell you how much they known about HRT. Dr: I'm glad you're here so we can discuss about it and address your concerns and hopefully by the end of the session you can make a decision regarding using HRT. Or hopefully by doing this discussion you will have a better understanding of HRT.

Or you can say: I agree with you as there are a lot of confusion about HRT and the reason for this confusion is that in the past because it was used to be given routinely to all women who reach a certain age, however 10 years ago there was study called " women health initiative" in which the authors found that the numbers of the patients with serious side effects are very high. However those ladies used HRT for a long time.

Serious side effects are Cancer, Heart attacks and Strokes.

For that reason the routine use of HRT was stopped.

Nowadays we have a better understanding and have better guidelines. Not only that we do it on the individualized basis.

We use it only for short time, they don't exceed five years.

So using HRT within five years is safe.

So I would take some information from you and we will discuss about the risk factors and if you are a good candidates we can make a decision to prescribe it or not. Dr: What makes you interested in HRT?

Patient: because of hot flushes.

At this stage if the patient gives you the symptom, it is your chief complaint. But if patient doesn't give you any symptoms, you should start with her LMP If she starts with the symptom of hot flushes, ask the patient

1.When did hot flushes start,

2.Is it all the time,

3.On & off or continues,

4.How many attacks,

5.Day or night,

6.How do you feel that you have it.

7.Night episodes, you have any night sweating, does it wake you up. Asked patient if the hot flushes wake her up during the night and if she needs to change her gown of night’s sweats.

1.Affect your sleep and how does it affect your concentration. 2.Change in your mood, anybody has told you that your short tempered, and if you 3.feel tired.

4.Some women with the same symptoms may notice some change in their sexual life. a)So the doctor should ask with whom do you live?

b)Are you sexually active?

c)Any dryness or pain during the intercourse?

5.Any change in your urination?

6.Have you ever lost control?

7.Last period?

•Are you periods regular or not?

•If it's irregular, when did it start to become irregular?

•Are your periods heavy or not?

•Any clots?

•*Any bleeding or spotting between periods? This is a very important point. 8.Bone pain? Any fractures? Any family history of osteoporosis? If yes, tell the patient that you will discuss this in another meeting. Because that's another session to discuss about using steroids, smoking, alcohol, caffeine, warfarin and diet. If she takes calcium supplements.

MGOS for GYN cases: Menstural, Gynecologic diseases, Obstetrics, Sextually transmitted disease

Dr: any history of gynecological disease like polyps, cysts, any pelvic intervention/instrumentation, surgeries.

Dr: did you use to take any oral contraception? If yes, which one and did you have any side effects?

Also you should ask about her last smear.

Because she is 50+ you should ask about her mammogram.

At any age you ask about Pap smear, once you reach 50 to ask about mammogram and when the patient pass 65 you should add bone density.

You can ask about her obstetrics history, like have you ever been pregnant if yes how many times you have been pregnant?

Now use the transition...

Because this is the first time I met you, I would like to ask you about your past medical and social history. Is there any long-term disease, hospitalization before, any surgery, diabetes, or hypertension. Any history of allergy, and the medication she takes.

ABCD: Active liver disease, vaginal Bleeding, Cancer, DVT

For A you ask about any history of Active liver disease. Have you ever been yellowish? Any dark urine or pay stool?

For B you should ask about any vaginal Bleeding? ... You have already asked these question before

For C you should check about Cancer. I would like to ask about constitutional symptoms here to see if there is any endometrial cancer. Fever, chills, weight loss, appetite, lumps & bumps. A history of cancer in yourself or family (breast cancer, endometrial cancer,and colon cancer).

For D you should ask about any history of swelling in the legs (DVT), any history of heart attacks, pulmonary embolism or stroke.

Social history: smoking, taking alcohol, recreational drugs, how does she support financially herself, how does this affect her life and ask about osteoporosis. Usually in this set of scenario, you tell her on the basis of the history you are good candidates for HRT.

However as I told you it is an important information to tell you to make your decision. As we go through different stages of life usually for ladies, we go to the stage called menopause which is vary between person to person.

At this stage there is hormonal changes and ovaries start to produce less hormones specialty estrogen and progesterone and that changes affect the whole body. It can explain about dryness, decreasing or absence of periods. And that's why we try to replace those decreased hormones by HRT. They are the same hormones but we give it through external sources either tablets or skin patches.

As I told you before there is a balance it's your decision to make. And the balance is to use it up to five years. Using more than five years would increase the risk of stroke, heart attack or some cancers depending on what we call it estrogen dependent that includes breast and endometrial cancer. And some studies showed that it might increase the risk of Alzheimer's disease.

So the risk of use for less than five years is not significant and still acceptable. So if you want to use it the shorter the better.

To get rid off the hot flushes that are other measures like exercise or herbal supplements that you can try to improve the symptoms.

The HRTs are the same as OCP's but in this smaller doses and you can take one tablet a day. They have a few side effects like weight gain, bloating, nausea, abdominal distention and pain but they improve by time. This serious side effects are headaches, swelling of the legs or chest tightness which whenever happen you should go to emergency room. By using these HRT's your periods may stop or you may see spottings.

If the patient had hysterectomy before you only give estrogen without progesterone, otherwise you should give both.

Because you take it regular shootout regular ultrasound scans to check the thickness of the endometrium

CARDIO



1.45 yr old Chest Pain x 45 mins ER History x 5 mins (MI)

Onset:

1.When did it start?

2.What were you doing at that time?

3.How did you get here today?

4.If you came in by Ambulance, did the paramedics give you a tablet to be kept under your tongue?

Course:

Was it sudden or gradual?

Position:

Where exactly is it hurting you the most?

Quality:

Can you describe the pain? Is it crushing? Knifelike?.......

Radiation:

1. Does it move anywhere else in your body 2. Does it move to the back?

Severity:

On a scale of 1 to 10 where one is minimum & 10 is highest, where would you place this pain?

Associated symptoms:

CVS:

•N/V,Sweating?

•Heart racing?

•SOB/Orthopnoea/PND?

•Have you been under stress recently?

•Cough with blood tainted sputum?

GI

•Acid taste in mouth? • Heart burn? • Dysphagia • Pud?

MSK

•Have you had any trauma to the chest • Are there any blisters on chest?

RS

•Did you have any flu recently?

•Cough with Phlegm?

CONSTITUNIOL Sx

•Do you have night sweats

•Loss of appetite & Loss of wt?

Alleviating Fcts:

What makes you feel better?

1. Rest? 2. GTN?

3.Antacid?

4.Sitting forward? Aggravating Factors:

1.Exercise/exertion?

2.Movements?

3.Deep inspiration?

4.Lying down?

5.Eating?

RISK FCTS:

I need to know additional information that could be related to your pain right now, and need to ask some further questions...... 1.Do you have a high Blood pressure?

• When,& what did your doctor have to say about it? • Were you put on medicatn?

2.Were you diagnosed at any time with an elevated Blood Sugar or were told you had diabetes? • When,& what did your doctor have to say about it? • Were you put on medication?

3.Have you ever had your cholesterol checked?

If yes:

• When,& what did your doctor have to say about it? • Were you put on medication?

4.Do you smoke?

If Yes;

How many & Since how long?

5.Do you take alcohol

6.Have you used recreational drugs? Cocaine?

7..Do you find time for regular physical activity?

8.Do you eat a lot fast food?

9.In your family has anyone had a heart attack under the age of 50?

CAUSES/Consequences & Symptoms:

1.Did you ever have a stroke?

2.Did you have a weakness or numbness?

Past Medical History:

1.Do you take any medications?/OTC or herbal products?

2.Are you allergic to anything?

3.Were you hospitalized at any time?

4.Did you ever undergo any surgery?

5.Were you ever diagnosed with Cancer?

6.Do you have a bleeding disorder?

7.Did you have any head/facial trauma since last 3 mo?

I need some more information about your family HTN/DM/MI/Stroke

Social History:

1.With whom do you live?

2.How do you support yourself?

MANAGEMENT:

• Rapid, targeted history and physical examination, with particular attention to onset of symptoms, contraindications to use of thrombolytic agents Absolute contraindications:

1.Previous intracranial hemorrhage;

2.Known malignant intracranial neoplasm,

3.Known cerebral vascular lesion,

4.Ischemic stroke within 3 mo EXCEPT acute stroke within 3 h;

5.Suspected aortic dissection;

6.Active bleeding or bleeding diathesis (excluding menses);

7.Significant closed head or facial trauma within 3 mo.

Relative contraindications:

1.History of chronic severe, poorly controlled HTN,

2.Severe uncontrolled HTN (BP > 180/110 mm Hg)c;

3.Prior CVA greater than 3 mo or known intracerebral pathology not covered above;

4.Traumatic or prolonged (> 10 min) CPR or

5.Major surgery (< 3 wk);

6.Noncompressible venous punctures;

7.recent (2–4 wk) internal bleeding; pregnancy;

8.active peptic ulcer;

9.current use of anticoagulants.

and evidence of high-risk features (tachycardia, hypotension, congestive heart failure)

Management

1.ECG STAT, then every 8 hours for the first 24 hours, then daily for 3 days.

a. In addition, repeat the ECG with each recurrence of chest pain

2.Baseline troponin STAT, (creatine kinase if troponin is unavailable) and then every 8 hours until enzymatic confirmation of the diagnosis

3.CBC to rule out the presence of anemia,

4.Baseline electrolytes,

5.Creatinine,

6.Fasting lipid profile (within 24 hours of presentation)

7.Liver function tests

8.Portable chest x-ray (CXR) STAT

9.Echocardiography to assess LV function after stabilization and treatment.

Echocardiography is also used emergently when there is suspicion of acute mechanical complications post-MI Therapeutic Tips

•The goal for thrombolytic treatment is a door-to-needle time of 30 minutes or less.

•The goal for primary PCI is a door-to-dilatation time of 90 minutes or less.

•Careful attention to maximum pain relief is important.

•In patients with right ventricular infarcts:

oavoid nitrates and diuretics

ouse fluids and inotropes to treat hypotension

•Administer beta-blockers early to all patients without contraindications. Increase the dose every 12 hours (every 24 hours for once-daily beta-blockers), if tolerated (monitor blood pressure and heart rate), until the patient has reached adequate beta-blockade (HR ≤ 5565 BPM).

•Start ACE inhibitors early. The choice of agent can depend on practitioner preference, hospital formulary or financial constraints for the individual patient.

•In smokers, the need to quit smoking should be reinforced early (within 24 hours) and frequently.

•Stool softeners are often used in the immediate post-MI period to prevent straining with bowel movements.

•Anxiolytics are often used on an as-needed basis in the immediate post-MI period.

Early Management of STEMI

Hx

OCD

PQRST

(if it is suspected to be ACS - stop at R and start primary survey) Primary Survey (If patient talks – Airway preserved, take Oxygen saturation and start Oxygen Stat – 4L/m through nasal prongs)

Vitals

Auscultation: normal air entry and normal S1, S2

IV lines (normal NaCl 50ml/hr to keep line open, from the other side take blood for: Troponin, CK-MB, Cr, BUN, Lytes, CBC, INR, PTT, LFT, Toxic., Alcohol, Lipids; and finger prick for Glucose)

ECG 12 leads and continue monitoring

Ask about Allergy and Viagra (if negative) Give ASA chewable (325mg)

Non-ST elevation: give Nitro x3 (S.L) if there is no benefit – give Morphine.

Continue

PQRST

AA&A

How do you feel now?

Ask Hx on CVS and GI (especially peptic ulcer)

CSx

RS

DVT

ST Elevation: do not go for DDx, Vitals (again)

RF

Nitro (2nd dose) Examination:

JVP

Listen to heart

Base of lung

Compare BP in both Upper extremities to r/o coarctation of Ao

CXR

Once there is no Aortic Dissection  Thrombolytics (should be clear to r/o: Peptic ulcer, recent surgery, pericarditis, aortic dissection, brain tumor, and stroke) Based on ECG – counselling

Counseling

Based on your ECG it is most likely you are having an heart attack. If stable – BP and HR are stable, but it is a serious condition, however it is treatable. Heart attack means that greater than one blood vessel supporting your heart is blocked by a clot that has to be reimoved. The medications are called clot busters. Based on ECG and no sign of pericarditis or signs of aortic dissection you are a good candidate for treatment. It is an effective medication, needs consent. 1% chance of stroke and we can start heparin.

PALPITATIONS



A 37 M/6wks [H&PE] B.30F/4wks[H&C]

Dd:

VITAMINS C

VASCULAR: SVT,Rapid atrial fibrillation,& V Tach

METABOLIC:Fever,Anemia,Hyperthyroidism,Acromegaly

NEOPLASTIC: Pheochromocytoma

SUBSTANCE ABUSE & PSYCHIATRIC DRUG INGESTION (sympathomimetic) Drug Withdrawl,Anxiety

CONGENITAL:WPW Syndrome

>48 hrs not panic attack

OCD:

O: When did it start? How did it Start?

Sudden/Gradual

What were you doing at that time?

C:

Does it come in bouts or Continous?

How often does it occur?

What was the duration of the attack?

D:

How long since you’ve had these palpitations?

How long does each episode last? / ? > 48 hrs?

PQRSTUV

Q:

Ask Pt to tap with his fingers the heart beat.

Does it Miss abeat/Racing/Slowing of heart beat?

S:

On a scale of 1 – 10 How has it affected the quality of your life?

T:

Does it occur even at night?Is it the first time or has it happened before?

Emphatize: I know it can be a fairly scary feeling

AA&A

A: What makes it worse:Coffee/Recreational drugs/Stress/Smoke(extrasystoles)Choclates/Alcohol A: Anything makes it better?

How was your health prior to the palpitations?

ASOC Sx:

CVS: Chest Pain/SOB/Orthopnea/PND/Dizziness/Sweating/N/VSwelling of feet/Cough

CNS: Weakness/Vision loss/Difficulty in finding words/Numbness or loss of sensation THYROID: Do you feel hot/cold

Do you have wt loss inspite of increased appetite?/Tremors?Shakiness?Sweaty palms & moist skin? PHEOCHROMOCYTOMA: Repeated headaches,with increased sweating

CARCINOID:Flushing/Diarrhoea

CNS:In last few weeks did you notice any difficulty in Walking,numbness,finding words? (Look for Sx/o Embolism) CONSTITUTIONAL Sx: Fever/Chills/Loss of appetite/Lumps & Bumps

RISK FCTS: Smoking/Alcohol (Holiday Heart)/Recreational drugs

PMH:

•Are you on any medications?

•Have you seen a psychiatrist?

•Any OTC/Herbal products/Cold meds/Asthma meds • Are you allergic to anything?

If Allergic to Penicillin:

1.When did you find out?

2.Where did you take it?

3.Why did you take it?

Do you have any Heart disease/HTN/DM/Stroke/Ca/MI H/O Rheumatic fever as a child?

Did you get repeated sore throat infections as a child?

Did you receive Penicillin injections regularly as a child?

HTN

History:

OCD

o O: *When did you notice your BP was high?

*When was your last (N) BP o Duration of hypertension,

*Usual level of blood pressure and

*Any sudden change in severity of hypertension o History of antihypertensive drug use,

*Reason for changing therapy,

*effectiveness,

*side effects and intolerance (IMPOTENCE) o Drugs that may cause hypertension drugs that may interact with antihypertensive drugs (those that induce or inhibit metabolism) o Adherence with lifestyle recommendations and drug therapy

HOME MONITORING

END ORGAN DAMAGE:

1.Angina/Mi: Chest pain/SOB

2.TIA/Stroke:LOC/Vision changes/weakness/Numbness

3.Peripheral Vascular disease/Leg pain/ED/

4.Kidney disease

SX of SECONDARY HTN, ,

1.Pheochromocytoma (hyperadrenergic symptoms)Do you have episodes of palpitations/HA/Sweating?

2.Hyper- and hypothyroidism: Feel Hot/Cold/Tremors

3.Cushing’s syndrome: Bruising of skin/Wt gain

4.Renal/urinary symptoms or a past history of renal disease

RISK FCTS:

1.Cigarette and alcohol use,

2.Usual physical activity

3.Usual diet and sodium intake,

4.Current weight and recent weight change, waist circumference,

5.Diabetes

6.Dyslipidemia

PAST MED HISTORY

1.Medications Pt is on/OTC/Herbal

2.Allergies

3.Hospitalizations/Surgery

FAMILY HISTORY

•Hypertension,

•Cardiovascular risk factors

•Premature cardiovascular disease

SOCIAL HISTORY

Nonpharmacologic Choices

Effect of Lifestyle Changes on Blood Pressure in Adults with Hypertension

Intervention Change in Blood Pressure (systolic/diastolic) mm Hg

1.Reduction in sodium ↓ by 1800 mg (78 −5.8/−2.5 intake mmol) per day

2.Weight loss 4.5 kg −7.2/−5.9

3.Reduction in alcohol ↓ by 2.7 drinks/day −4.6/−2.3 intake

4.Exercise 3 times/week −10.3/−7.5

5.Dietary DASH dieta −11.4/−5.5 recommendations

•Weight loss of 4 kg or more if overweight (target body mass index: 18.5 to 24.9 kg/m2; waist circumference <102 cm in men and <88 cm in women).

•Healthy diet—high in fresh fruits, vegetables, soluble fibre and low-fat dairy products, low in saturated fats and sodium, e.g., DASH diet available at Sodium intake of 1500 mg (65 mmol) per day for those aged 19–50 years, 1300 mg (56 mmol) per day for those aged 51–70 years and 1200 mg (52 mmol) per day in those 71 years and older.

•Regular, moderate intensity cardiorespiratory physical activity for 30–60 minutes on most days.

•Low risk alcohol consumption (0 to 2 drinks/day, < 9 drinks/week for women and < 14 drinks/week for men).

•Smoke-free environment.

SYNCOPE



Volume depletion and drugs Volume depletion

•Diarrhea

•Diminished oral intake

•Polyuria

Drugs

ACE inhibitors

oAlcohol

oAlpha- and beta-adrenergic blockers o Antiparkinsonian drugs o Diuretics o Nitrates

oPhosphodiesterase type 5 inhibitors (sildenafil, tadalafil, vardenafil)

o Vasodilators Orthostatic intolerance disorders

•Reflex syncope syndromes o Carotid sinus hypersensitivity o Vasovagal syncope syndromes

•Autonomic neuropathies o Pure autonomic failure syndromes o Multiple system atrophy syndromes

•Arrhythmias

1.Bradycardias oComplete (third degree) and bifasicular heart block o Sinus node disease

2.Tachycardias oSupraventricular arrhythmias (uncommon) o Torsades de pointes polymorphic ventricular tachycardia o Ventricular tachycardia

Obstruction

•Aortic stenosis

•Pulmonary emboli

•Many other rare causes

Investigations

In patients with transient loss of consciousness perform a complete cardiovascular and neurologic history and physical examination. Rule out seizures, then screen for life-threatening causes such as obstruction, ventricular tachycardia and asystole or heart block

•Tailor laboratory investigations to the individual patient:

oECG (most patients)

oolder patients ( >55 years) should have ambulatory ECG monitoring unless the history is strongly persuasive for vasovagal syncope.

oechocardiogram or other noninvasive measure of left ventricular function if structural heart disease is suspected

ocoronary angiography as indicated o refer patients with structural heart disease for electrophysiologic assessment o unless contraindicated, carotid sinus massage should be performed in patients >50 years old to screen for carotid sinus hypersensitivity (do not perform in patients with carotid bruits)

otilt table testing might be useful in diagnosing vasovagal syncope in patients with atypical symptoms

•After potentially fatal causes are eliminated and reversible causes are removed, most patients will have one of several syndromes of orthostatic intolerance:3 o reflex syncope syndromes

•vasovagal syncope

•carotid sinus hypersensitivity in the elderly o pure autonomic failure syndromes o multiple system atrophy syndromes

•The orthostatic intolerance syndromes can be distinguished based on history and a simple stand test in the office. To perform the stand test, first measure blood pressure and heart rate after the patient has been supine for 5 minutes, then after 2 and 4 minutes of standing. These responses are seen: Normal and vasovagal syncope: modest rises in heart rate (about 10 BPM) and blood pressure (about 10 mm Hg). Autonomic failure: progressive fall in blood pressure of ≥20 mm Hg systolic or ≥10 mm Hg diastolic with development of presyncope; often no increase in heart rate.



Treatment is directed at the cause of syncope. Treat any reversible causes. Refer patients with syncope secondary to bradycardia (asystole or complete heart block) for a permanent pacemaker. Refer patients with suspected or diagnosed ventricular tachycardia, and all patients with structural heart disease to a cardiologist, preferably an electrophysiologist. The following addresses treatment of syndromes of orthostatic intolerance. Nonpharmacologic Choices •Reassure the patient that this syndrome is not life threatening and that it is a physical problem, not a psychiatric disorder. Encourage increased dietary salt intake of about 3–5 g daily, in the absence of contraindications such as hypertension or heart failure.5 , 8 •Teach the patient to use physical counterpressure manoeuvres at the onset of presyncope.9 , 10 These include squatting, crossing the legs with isometric contraction if standing, and vigorous hand clenching with upper girdle isometric contraction. All should be tried. The evidence is based on a good physiologic study10 and an open label randomized clinical trial.9 •Pacemaker therapy is no longer indicated, based on the results of an adequately powered randomized placebo-controlled trial.11 The occasional patient with asystole documented during vasovagal syncope might benefit, and these uncommon patients should be assessed at a tertiary referral cl

65/F Calf Pain x 10 weeks





How many blocks you could go? How many now?

How fast the pain disappears after resting?

Is the pain alleviated by bending forward or extending backward? Is it awakening you at night? Ddx:

1.Spinal Stenosis (Pain disappears about 15min after resting, alleviate by leaning forward)

2.Disc herniation (Pain disappears about 15 min after resting, alleviated by extending)

3.Intermittent Claudication (After resting – pain disappears by few minutes)

4.PE

5.Cellulitis

6.Ruptured Baker’s cyst CC:

Unilateral Vs (B) O:

Can you tell me when it all started?

Sudden Vs Gradual

What were you doing at that time?

What made you come in today?

C:

Is it Increasing,decreasing or same? Has the intensity increased?

*Does it awaken you up at night?

D:

How often does each episode occur?

How long does it last?

PQRSTUV:

R:Does it move anywhere else in the body? Buttock/Toes/Feet/Thigh T:When does it come on?

When you walk?

How many blocks can you walk when it comes? ------ >Now & at the beginning? Reproducible pain

U

V:

•Has it happened before?

•If Yes When?

•How Often?

AAA:

AGGRAVATING:

Stand/Sit?

When you walk uphill or downhill?

When you raise your leg?

ASSOC. SX:

CONSTITIONAL Sx: Fever/ /night sweats/Loss of appetite & los of Wt/Lumps & bumps. Local Sx:

1.Swelling/Raised temp

2.Back Pain or Trauma to back or knee/Morning stiffness

3.Numbness/Tingling/Weakness/Burning sensation 4. Change in nails/Hair loss/Skin is it shiny/any Ulcers?

5. Are your feet cold? CARDIAC:

Chest pain/Palpitations/SOB *How is your sex life? Desire & Erection?........ How has this affected your life?

RS:

Cough

RISK FCTS:

I need to ask you some more qns that will help me arrive at a diagnosis of your pain: 1.Do you Smoke? 2.Drink Alcohol? 3.Have you recently travelled a long distance in an airplane? 4.Were you at any time Diagnosed as HTN,Is it Rxed & Under control? When was the last time you saw your Dr.? 5.Were you at any time Diagnosedwith high blood sugar?Is it Rxed & Under control? When was the last time you saw your Dr.? 6.Have you checked your cholesterol? ....... 7.Did you have recent surgery?

PMH:

I need some information about your health in general: •Are you on any meds?/OTC/Herbal products? •Allergies? •Were you ever hospitalized?

FHx

SOCIAL:

•Who lives with you? •How do you support yourself financially?

ANKLE SWELLING 30 M x 10 days



A. Gout B. CHF Dd: A. UNILATERAL 1.Trauma 2.Arthritis: Gout/SepticA 3.Cellulitis 4.Varicosities B. BILATERAL 1.CHF 2.Nephrotic 3.Liver failure 4.Myxoedema 5.Protein losing enteropathy First Qn: Unilateral or Bilateral OCD: O; Sudden/Gradual Off & On/Continous Everyday/Certain time of day Related to activity/Standing PQRSTUV: P:Above kne/Below knee Posture

AA&A What makes it worse: Activity/Alcohol & diet(Gout)/Standing Alleviating fcts:Rest with elevation of feet....

ASSOC Sx:

LOCAL Sx:

In addition to the swelling did you notice any: Pain/Stiffness/Fullness/Redness Did you notice swelling anywhere else? Face/Eyes particularly did you feel your eyes were puffy in the morning/Increasing waist size/Rings are tighter? CONSTITUTIONAL Sx: Fever/Wt loss/Night sweats/lumps & bumps CARDIAC Sx: Chest Pain/SOB/Heart racing GI/LIVER Disease:Yellow discoloration of skin/Pale stools/Dark urine KIDNEY DISEASE:Change in the amount of: Urine/Color/Consistency (Frothy/Cloudy)/Odour RISK FCTS: I need to ask you some more details to get more insight into your condt: Do you Smoke,Take Alcohol or Recreational drugs? What is your diet like? Do you eat a lot of red meats? (GOUT)

PMH:

Any meds you’re currently taking?(*Aspirin & Thiazides for gout)/OTC/Herbal products? Have you ever been diagnosed with HTN/DM/MI/Stroke/Ca? Were you ever hospitalized or undergone any surgical procedure? FH:

Does anyone in the family have a similar condt?

DM/HTN/MI/Stroke?

SOCIAL H: Who lives with you

How do you support yourself financially?



24 female, acute asthma in ER, 3 dasys ago,asthmatic for the last 3yr comes to you at clinic for F up As I understand you were in ER 3 days ago with an attack of Ac asthma. HOW DO YOU FEEL RIGHT NOW?

Event – Before Event After OCD Can you tell me what happened at that time? SX: 1.Sudden/Gradual 2.Was there Wheezing? 3.Chest tightness? 4.Were you able to talk? 5.How many times did you use the puffer? 6.How did you get to the ER? 7.What did they do in the ER? 8.Were you intubated? 9.What medicines did they give you?

Asthma history

Let us talk about Asthma history: 1.When were you diagnosed? 2.How were you diagnosed? 3.Are you on regular f/Up? 4.When was the last time you were seen at F/up? 5.Have you visited the ER before? 6.Did you notice any increase in nos of attacks? 7.Do you have attacks at rest? Attacks at Night? 8.Did you dr adjust your meds at that time? 9.Which meds do you use? 10.How often do you have to use your medicines? 11.Are you using the meds more frequently? 12.Triggers 13.Do you suffer from heart burn or condt called GERD? 14.Do you user a peak flow meter?

I need to ask more qns which will help me to clarify as to why you had an attack recently? 1.Have you had recently any flu/infection? (any chest infection upto 10 wks post infection hyperreactive airways) 2.Can you show me how you take medication? (Shake it, put it in your mouth, take deep breath when puffing). 3.Do you make sure your medication are not expired and stored expired? 4.Did you started any new medication that might interfere (beta blocker / aspirin)with your asthma? 5.Outdoor – cold weather, pollens, exercise, construction, dust 6.Indoor – a.Do you smoke or anyone around you, b.Pets or people around, c.New curtain, indoor plants, carpets, curtains, pillows. d.Basement – mould, renovations, paintings; 7.Relation to any type of food; 8.Strong odour

Important to classify – mild / moderate / severe

I want to ask you…

What do you do for living? PAST H: Any HTN/DM Hospitalizations/Surgery FAMILY H: Same Condt DM/HTN/Stroke SOCIAL H Do you take alcohol/recreational drugs? How do you support yourself financially?

Asthma Treatment

Very mild, intermittent asthma may be treated with fast-acting beta2-agonists taken as needed. Inhaled corticosteroids (ICS) should be introduced early as the initial maintenance treatment for asthma, even in individuals who report asthma symptoms less than 3 times a week. Leukotriene receptor antagonists (LTRAs) are second-line monotherapy for mild asthma. If asthma is not adequately controlled by low doses of ICS, additional therapy should be considered. A long-acting beta2-agonist (LABA) should be considered first as add-on therapy only in combination with an ICS. Increasing to a moderate dose of ICS or addition of an LTRA are third-line options. Theophylline may be considered as a fourth-line agent in adults. Severely uncontrolled asthma may require additional treatment with prednisone. Omalizumab may be considered in individuals 12 years of age and over with poorly controlled atopic asthma despite high doses of ICS and appropriate add-on therapy, with or without prednisone. Asthma symptom control and lung function tests, inhaler technique, adherence to asthma treatment, exposure to asthma triggers in the environment and the presence of comorbidities should be reassessed at each visit and before altering the maintenance therapy. After achieving proper asthma control for at least a few weeks to months, the medication should be reduced to the minimum necessary to maintain adequate asthma control. Short-acting Inhaled Beta2-agonists (SABAs)

Salbutamol and terbutaline are selective beta2-agonists that are agents of first choice for treatment of acute exacerbations and for prevention of exercise-induced asthma. They are best used as required rather than on a fixed schedule. Although potent bronchodilators, they have little effect on the late (inflammatory) phase of an exacerbation. If patients use a short-acting beta2-agonist more than 4 times per week (including any doses used to prevent or treat exercise-induced symptoms), initiate therapy with an anti-inflammatory agent.4 Isoproterenol and epinephrine are not recommended for the treatment of asthma because of lack of beta2-selectivity and potential for excessive cardiac stimulation, especially at high doses.

Long-acting Inhaled Beta2-agonists (LABAs)

Salmeterol and formoterol are long-acting beta2-agonists for regular twice daily treatment of asthma. Salmeterol has a slow onset of action and should not be used for immediate relief of bronchospasm. Formoterol is rapid acting and can be utilized for rescue therapy. These drugs help to prevent exerciseinduced bronchospasm.5 Both should be used only in patients already taking inhaled corticosteroids and may be particularly useful for the prevention of nocturnal symptoms. Adding long-acting beta2-agonists to 6 inhaled corticosteroids may permit decreasing the latter’s dose.

This information was originally published in Canadian Respiratory Journal 2010;17(1):15-24.

ACUTE COUGH

Cough for the last 5d

Local Cause Community acquired Pn HIV In young Pt can ask directly H/o HIV Status In HIV(Pneumocytis Jevorici there is (B) chest pain & night sweats OCD:UV

O How did it start: Sudden/Gradual? C: Is it first time or have you had it before? Is it increasing/Decreasing or same intensity now as it was in the beginning? Does it wake you up from sleep? EMPATHY if awakens him up NATURE: Dry/Wet If Wet: COCA Color Odour Consistency Amount Blood CHEST PAIN: PQRST Constitutional symptoms RESPIRATORY Sx: 1.Shortness of breath, 2.Tightness, 3.Wheezing, 4.Ear pain 5.Sore throath CARDIAC Sx: SOB/ Heart racing Chest ain S/o Meningitis:

RISK FCTS: 1.Recent contact with sick people, 2.Vaccination for flu 3.TRAVEL H 4.Smoking 5.Alcohol 6.Drug abuse Past Med H Any meds/OTC/Allergies Asthma/DM/Similar condt Hospitalizations/Surgery FAMILY H SOCIAL H: Habits IF HIV + PT:

DO you know your HIV diagnoses? *When? *Where? *Regular follow up? *Medication? Taking/or not? *Last CD4? *H/O Thrush? PAST MED H Allergy COUNSELLING: PE/ CXR & Bl work Admit today

Cough for the last 6w



Increasing, not improving DID you seek medical attention?, what make you come today? Is it the first time? OCD O How did it start: Sudden/Gradual? C: Is it first time or have you had it before? Is it increasing/Decreasing or same intensity now as it was in the beginning? Does it wake you up from sleep? EMPATHY if awakens him up What made you come in today/ NATURE:

Dry/Wet

If wet first & then dry 2 elements: 1.Previous episode Sx: When productive:Fever/chills/Night sweats/ muscle pain & joint ache/COCA 2.Dry cough Sx: From that time till now,do you have fever?chills,muscle pains? Sx of infection? PATTERN OF COUGH: 1.Whole day? 2.How often? 3.How may attacks? 4.How long each attack? 5.Any particular time of the day?or 6.Do you wake up in morning with cough?(NIGHT COUGH: GERD/Asthma/CHF) (MORNING COUGH: PND/GERD) 7.When you cough do you cough to the extent that you’ve: a.SOB b.Difficulty talking c.Wheezing d.Chest pain e.Sweating f.(in children----> vomit) RISK FCTS: I need to ask some qns now that could lead me to the cause: •H/o repeated sinusitis •Facial pain •Ned to clear throath •Runny nose •GERD: H Burn Acid taste in mlouth Relation to lying down/bending forward How many pillows do you need at night Do you get up in night gasping for breath/

•ASTHMA; h/o Asthma

Relation between cough & outdoors or indoors • SMOKING H: Self: How many/ How long Those around you •Pets What do you do for a living/ Any exposure to dust? Any perfumes? D/D Other causes of Ch Cough 1.Medications: a. HTN; ACE/Aspirin/NSAIDS 2.Swelling in legs 3.Rcent travel 4.Contact with Tb 5.H/o Lung Ca

CHEST PAIN: PQRST Constitutional symptoms RESPIRATORY Sx: 1.Shortness of breath, 2.Tightness, 3.Wheezing, 4.Ear pain 5.Sore throath CARDIAC Sx: SOB/ Heart racing Chest ain S/o Meningitis:

67Male with Hemoptysis



Same check list as H Uria look for pulmonary Sx

Intro: As I understand you’re here because you’ve cough x 1 week? Any chance you may be vomiting? OCD Duration: Night? COCA + Bl Sx of Hypovolemeia: Dizziness/Faint/Tiredness/Loc A & A ASx: RS CSx: Hoarse voice Risk Fcts; Smoking Contact with TB/Screened for TB Travel outside Canada Exposed to asbestos H/O Dvt,Calf pain,redness,swelling of calves H/O Hd: PND/Orthopnea H/o Blood thinners Bleeding from any parts of body CNS: PMH

SOB/67 F x 6wks [5min/H]

HF

Dd: VITAMINS

VASCULAR:CHF,ACS,PE Precipatants of CHF:

•Meds: * Stopped * NSAIDS •Increased Na intake INFECTIONS:Pneumonia TRAUMATIC:Pneumothorax METABOLIC:DKA IDIPATHIC/IATROGENIC:COPD/Asthma/Massive atelactasis NEOPLASTIC: Large pleural effusion FIRST evaluate:ABC,ask pt if she is comfortable....... OCD: O:Sudden/Gradual What were you doing when you had this SOB? ---Exertion/Lying down? C: *SOB first always ask if difficulty in breathing is for: Breathing IN or Breathing OUT Does it occur all the time or only now Is it related to activity or does it occur even at rest If brought on by walking? How many blocks can you walk now as compared in the beginning? If at Rest? Do you sleep well? How many pillows do you need? Do you wake up at night gasping for breath? D:

How long?

If assoc Leg swelling,---- How long since leg swelling? PQRSTUV: S: On a scale of 1 – 10? T: Has it ever happened to you before?If so,how often? When was the last time you had SOB? How did you cope? U: How has it affected your life & how do you manage? Do you have someone to help you? [EMPATHY] AAA AGGRAVATING FctS: Exercise POsition Exposure to cold air? Infection? Allergies? ALLEVIATING FctS;

ASSOCIATED SYMPTOMS:

CONSTITUTIONAL Sx; Fever/Chills/Wt loss/Lumps/Bumps RS: Cough/Sputum GI: Dec appetite (Liver & GI congestion) Increase in waist size (Ascitis) CVS: Wt gain/weakness/Fatigue (Decreased cardiac Output) Chest pain/Sweating/N/V/Heart racing/dizziness/Nocturia Leg Pain/Leg Swelling/Wt gain THYROID: Do you feel cold/Hot /tremors RISK FCTS: I need some more details about you to get a better understanding abt your condt & hence need to ask you a few more qns Do you smoke? Take alcohol? *Take your meds regularly? *Any change in your diet recently? --- Are you eating more canned foods or have you been taking salted nuts *Do you measure the Na in your diet? Did you notice you’re pale? PMH: Were you ever diagnosed with HTN? What meds do you take? Have you taken your meds regularly? Were you ever diagnosed with a heart condition? Which HD?When were you diagnosed? How were you diagnosed? Do you have regular follow ups? When was your last F up? During your last visit, did your Dr add or remove any medications? How were you doing? Were your symptoms controlled at that time? Particularly ask about Dixogin: How much/How long/Dose/did you have your levels checked/any chance that you might’ve missed a dose? Particularly ask about Water pills: NSAIDS DM/MI/Cholesterol/Stroke/Ca/Hospitalization/Surgery FH: FH of premature deaths

SHORTNESS OF BREATH – POST SURGICAL



Surgery 3 days ago: SOB x 45 mins D/D: 1.Volume status (low & High) 2.Atelectasis 3.Pneumonia 4.Heart Failure 5.Embolism 6.Fat embolism INTRO: As I understand, you’d surgery 3 days ago & I’ve to do a PE on you VITLAS please I would like to R/O orthostatic hypotension Respiratory Rate G/E: Orientation: • Time •Place •Person Head: Sclera & Pallor Mouth: S/o dehydration No Central cyanosis No nasal flaring or pursed lips No S/o Respiratory distress HANDS: Capillary refill

Clubbing

Cyanosis Skin: Hot/Cold Pulse: Rate & Volume LEGS: Dorsalis Pedis Temperature Pedal oedema Feel for DVT Measure diameter of (B) calves Homann’s sign NECK: JVP Trachea S/o respiratory distress & use of accessory muscles of respiration L Nodes for pneumonia CHEST: Inspection: Symmetrical No IC retraction No accessory muscles No obvious pulsations No PMI seen FEEL Apex beat

LUMP In Breast/Neck



40/F h/o lump in Breast x 8 wks INTRO: As I understand you’ve a lump in your breast since 8 weeks, can you tell me more about it since it all started?

OCD:

O: HOW did you notice it? Routine examination or Accidentally? C: From that time to now, is it increasing, decreasing or remaining the same? V: Is it the first time, or have you noticed it before? Any relation to periods? Did you notice it on the upper or lower half of breast or inner or outer side? Do you feel it reaching into the arm? SIZE: How do you estimate the size? Chickpea/Olive/egg/Orange? Hard/soft/rubbery? Pain+/- Skin: slides or fixed? Changes in skin above: redness/ulcers Lumps in other breast Nipples: Dischareg/changes/ulcer? CSX: TRAUMA to breast? METASTASIS: Ha/Nx/Vx/Back pain/Cough/numbness in hand/Tired/pruritus? I’m going to ask you qns that may explain this:

RISK FCTS:

1.H/o Ca in breast or other breast? 2.If any biopsy was performed on the breast? 3.FH of Ca breast 4.LMP 5.Have you ever been pregnant & at what age your first pregnancy? 6.Have you breast fed? 7.Any OCs & for how long? 8.Do you smoke/alcohol? 9.H/o Ovarian or uterine Ca 10. Fatty Diet?

LUMP IN NECK:16/F X 2 WKS



D/d: Reactive Adenitis --------> Recent Flu Tooth problems ---------> Lymphoma ----------> Hard IM HIV INTRO: WHERE? HOW : OCD: SIZE: FEEL: Pain +/- SKIN changes Any other lumps? CSx: Sore throat / dyspahgia? Hx/Nx/Vx? Skin rash? Ear discharge? Sinusitis/cough/Pglem? H/o Ca or malignancies? HEADSS Abd pain Vaginal discharge Urine changes PE: Vitals: Look & asses the lump Look for any other lumps: Cervical LN/Supraclavicular/axillary Mouth PA: Liver & spleen Groin LN Popliteal fossa Pelvic & Vaginal exam Rectal exam Back to Content

TIREDNESS 45M with tiredness x 6 weeks As I understand you’re having Tiredness since 6 weeks, can you tell me more about it since it all started? Pt says he is concerned. STOP & ask about his concern. He says he is Air traffic controller & his vision has been blurry Pt says, he is also never been so tired before. Clarify: What do you mean about Tiredness? •Sometimes I do not feel refreshed after sleep. •Do you feel lack of energy? Like you cannot move your arm above your head. The Statement: NOT REFRESHED ANYMORE points to an organic cause OCD + Relation to sleep +/- Mood If Mood Sx + ------ MOAPS If Organic cause ---- Red Flags OCD At onset you can ask if there were any flu-like Sx initially (Thyroiditis) •Do you sleep more •When do you go to bed? •Do you wake up in the middle of the night •Which time of day/Night do you feel most? •Ask Nature of work; If shift •With whom do you sleep? •Does your partner C/o you snoring or jerky movts of limbs? (Restless Leg) •Do you feel better in morning or evening(if tired in morning-->Depression If evening-------->Organic cause)

1.Ask Constitutional Sx first: Fever/Wt loss/Night sweats/Chills/Lumps & Bumps Then quick review of Sx: 2.Cardiac: Chest Pain/SOB/Palpitations 3.Pulmonary: Cough/Wheezing/Phglem 4.GI: N/V Abnormal bowel movts/Diarrhoea/Malena/ 5.Liver: Dark urine/Yellow sclera/Abd pain/Loss of aooetite/Pale stool/Itchy skin 6.GU: Change in color of urine/Amt of urine/Cloudy/Frothy urine/Dysuria/Facial swelling 7.Anemia: Bleeding gums/Easy bruising/Malena/Haematuria/Female: Meorrhagia & LMP 8.Autoimmune Disease: Joint Pains/Skin rashes/Oral Ulcers 9.Endocrine: Thyroid: Feel hot/Cold Skin Moist/Dry/Tremors/Wt loss 10.DM: Risk fcts: FH & Lifestyle Once Pt has DM in history, GO over ALL Sx & Sy: A. Fluctuating 6 Sx 3 High: 1.Increased eating 2.Inc Drinking 3. Inc urination 3 : 4.Tired 5.Wt loss 6.Blurry vision B. Complications:  Micro: 1.Retinopathy: Black spots 2.Neuropathy: Tingling/ numbness 3.Nephropathy: Inc Urine 4.Impotence: Sometimes people with this condition have marital problems; Do you have changes in desire or difficulty in having or maintaining an erection? 5.Autonomic Dysfn: •Orthostatic hypotension •Gastroparesis •Diarrhea •Voiding difficulties •HTN  Macro: 1.Coronary Artery Disease: Chest Pain/SOB/ 2.CVA: Weakness/numbness/difficulty finding words/Sudden visual loss 3.Peripheral Vascular disease: Pain in calves/Cramps/Cold feet Skin infections Candidial infections in women

RISK FCTS: 1.Diet 2.Exercise 3.FH 4.Smoking 5.Alcohol 6.Recreational drugs

PAST MEDICAL HISTORY: Any medications/OTC/Herbal/LMP Surgery/Hospitalization

FAMILY HISTORY: DM/HTN/Stroke/MI

SOCIAL H: Habits With whom do you live? How do you support yourself financially?

Here Counselling should be short Focus on Blurry vision in relation to DM & why he needs to correct it. As I told you DM is a lifelong disease & it is imp to have the BSL controlled. Without proper BSL control, the increasing Blood sugar damages the blood vessels in our body, & leads to heart attacks, Strokes, Kidney failure. Also visual loss & feet ulcers I will have to refer you to a diabetic clinic However I will do basic blood inv & ECG first

35 M in hospital setting had a DKA 3 days ago x 5 mins H He is diabetic since 25 years



Here we’ve to look for Rf & see that are not repeated

As I understand you were seen in the hospital by my colleagues & Rxed for a condt called DKA 3 days ago. Can you tell me what exactly happened to you at the time? Xxxxx 1.Was there abdominal pain 2.Vomiting? 3.Were you drowsy? 4.Was there loss of consciousness? 5.How did you get to the ER?

6.When were you Diagnosed ad Diabetes? 7.How were you Dsed? 8.What type of Dm? 9.Which medications do you take/ 10.Insulin? 10.1How much? 10.2When was the last time your insulin was adjusted? 10.2 What was the wt at that time/ 11.Any loss or gain of wt? 12.How often do you monitor your bl Glucose? 13.When was the last HbA1c 14.Did you have DKA before? 15.When was the last time you had it/Are you under regular F/U? 16.How were you doing for the last few mths? Ask about Sx control: Blurry vision Inc thirst Inc Peeing Wt loss

Any idea why Sx are not controlled? DIET What about diet? How often do you party? Do you modify your diet when you party? Do you adjust insulin when you party/ If you take alcohol do you count it as a part of your calories EXERCISE: Any RECENT INFECTION/FEVER?

LONG TERM COMPLICATIONS: Have you ever had an eye check/ When was the last time you saw an ophthalmologist? Any retinal complications/ Any H/o heart attack? How are your feet/ Any feet ulcers? How is your urine,is it frothy/Cloudy/ Do you have tingling/numbness Thank you for the information,we will have to do further assessment 38M requesting a note to say he is well & fit to work Cannot see at work, works as an accountant.

ABDOMINAL PAIN/ACUTE ABDOMEN



1. Acute abdomen x 24 hrs 45/M Er x 5min H 2. Dysphagia x 6 wks 55M 3. Inc LFT: a.35 M ALT>>AST b.55M AST > ALT 4. Diarrhoea: a.Ch Diarrhoea x 6 wks H & PE b.Ch Diarrhoea x 6 wks H & C c.Ac Diarrhoea x 3 days H x 5mins

AC ABD: Acute abdomen x 24 hrs 45/M Er x 5min H As I understand you’ve abdominal pain since 24 hrs. Are you comfortable sitting down? Please bear with me for 5 mins till I find the cause of this pain & then I can give you something for relief OCD: O: Gradual/Sudden C: From the onset till now,is it: Inc/Dec Off & On/Ct-ous How was it at first? When change in course,QUALITY & SEVERITY is significant P Q: Ask nature from beginning R S T: Any relation with time? Before eating/After eating U: How was your sleep? V: Alleviating: Eating/Antacids/Defecation/Meds? Aggravating Fcts: Food/Posn/Alcohol/Meds? Assoc Sx: •Nausea •Vomiting: If +ve: *Color *Odour *Consistency *Amount *Forceful *Does vomiting relieve pain? *What started first: Vomiting or pain? (If V 1st --Infection/ If Pain 1st Surgical) BOWEL CHANGES: *When was the last bowel movt? *Any abdominal distension? *Is there any blood in stool/Dark stool? *Are you passing any gases? APPETITE CHANGES: Sx Dehydration: *Dizziness *Dark Urine LAST MEAL: *Did you eat alone? *Was there anything new? * Did others have same Sx? RISK FCTS: *Any Past H/o Abdominal Surgeries * Crohn’s disease? * Groin surgery(hernia repairs) * Gall Bladder stones? * Pancreatic stones * Diverticulitis? *Smoking *Alcohol

CONSTITUNIOL Sx: Fever/Chills/wt loss/Lumps 7 bumps CVS: Chest Pain/Hd/HTN FH; Ca Colon/Polyposis PAST Medical h: Meds: Aspirin/OTC/Herbals/LMP

71F/Abd pain after meals x 4 weeks [10 min H]



(ischemic) Dd: 1.GERD 2.PUD 3.Gastric Ca 4.Ischemic Mesentry 5.Pancreatic failure 6.Ischemic colitis Here Pt was concerned that spouse died of Ca Stomach.Reassuare her that unlike Flu Ca Stomach is not contagious, but because they were married for so long there might be a chance that they were exposed to a risk fct.But you will conduct a thorough History & Inv

OCD

PQRSTUV A&A Assoc Sx: •Constitutional Sx: •GI Sx: *N/V/D *Malena *Bowel movts * Abdominal bloating • Cardiac Sx: *Chest Pain/Palpitations/SOB RISK FCTS: HTN/DM/Smoking/FH of HD/Cholesterol?HD If +ve for HD •Ascertain type & when diagnosed,enquire abt F ups •When/what & if intervention PMH: •Any meds/OTC/Herbal •Hospitalization & Surgery FH Social H: Here since Pt had Cardiac Sx.Your cardiac history is of concern to me & I’ve to do a PE & perform some blood inv & an ECG & then ask for a Surgical Consult

DIARRHOEA



Bloody Diarrhoea: Awakens at night? Any constant pain? Think Inflammatory bowel disease

Always ask about antibiotic use: if yes: 1.Why 2.Which Ab 3.For how long 4.When In acute Diarrhoea look for dehydration In ch diarrhoea look for Wt loss & then dehydration

Bad Diarrhoea if: +ve for fat droplets Floats Undigested food Bulky

After intro: OCD Frequency COCA + Blood Impact PAIN ASx D/d: 1.GE: if fever/N/V 2.Travel 3.New restaurant 4.Antibiotic 5.Osmotic PMH Fh Sh

24 yr old diarrhoea x 3 days

Introduction: Tell me more about is since the moment it all started? O C: How often do you go to the wash room? Estimated amount of stool passed? Is it Tarry? Mixed with blood? Any undigested food? Bulky? Is it offensive? Does it float in toilet bowl? Is it difficult to flush? A&A Did you try any meds/did they help

ASx: Do you feel dizzy/Thirsty? Do you drink enough fluid? Have you lost wt? Do you have any additional Sx like abdominal pain? Does bowel movt relieve your pain? N/V CSx: Did you eat in a new place? (raw food----Shigella) Did you recently take any antibiotics? Anybody else in the family has diarrhoea? Any FH of Bowel disease? Or condt called Crohn’s Disease? FH SH

24 yr M Diarrhoea x 6 weeks (Crohn’s) Can you tell me about it? O C: All the day?/At night/ D COCA + Bl

Bulky

+ Fat droplets Floats & difficult to flush Undigested food PAIN Relieved by diarrhoea or not Distension/gases U: How has it affected your life How do you deal with it? V: CSx: Extraintestinal Sx: Skin rashes/nail changes/Joint pains/back pain/Hx of psoriasis/Back pain/red eyes/Morning urethral discharge/ D/D: Thyroid :tremors/sweating Relation of diarrhoea to food like dairy products Travel or camping history Sx of Liver disease FH of Ulcerative colitis/Crohn’s SH

DIARRHEA x 6 wks



(Irritable bowel disease)

Dd:

1.IBD 2.Infection: camping/travel 3.Hyperthyroidism 4.IBS 5.Lactose intolerance 6.Coeliac Disease 7.HIV 8.Ch Liver & pancreratic failure OCD COCA + Blood + mucus PAIN:if +ve which started first Pain or diarrhoea Does bowel movement relieve the pain? Does it awaken you at night? Do you feel you want to go back to wash room again? Distension/gases U What made you come in today?

V:

DIET: dairy products C Sx: In IBS R/o Organic cause: Stress? What type; Family/Job How do you cope with it? How is your mood/Interest? FH: of Ca Colon at young age SH

42 M with Bld work LFT INCREASED:



ALT:300 AST:100

Cc: Bld works Intro Talk about blood works: 1.WHY? 2.Is it 1st time 3.When 4.Who 5.If done before: what were results then?

SPIKE EXPLAIN Results CONSEQUENCES: Sx. Ac & Ch CAUSES OF LIVER DISEASE: PMH FH SH

Intro: As I understand you’re here today to discuss some of your blood tests results Is it 1st time/ Why/who/When EXPLAIN: Results show that there is an increase in the markers to measure the function of the liver, called liver enzymes, this indicates that there is an injury to the liver cells There are different causes, but before coming to the causes, I want to know if there are any Symptoms of liver disease Ac Sx; 1.Yellow discoloration of skin/eyes 2.Pale stools/Dark urine 3.Itchy skin 4.Loss of appetite/nausea/distaste for cigarettes 5.Flu like Sx few weeks ago Ch Sx;

CAUSES OF LIVER DISEASE

1.Have you ever been diagnosed as liver disease before? 2.Have you ever ben screened for liver disease before? 3.Have you ever been vaccinated for Hepatitis A or Hepatitis B before? TRANSITION I want to ask qns now as to whether you were exposed to liver disease: 1.Do you smoke? Take alcohol/Recreational drugs? Past use IV drugs 2.Tattoos 3.Any past surgeries/hospitalizations 4.FH of liver disease 5.Long term disease in past 6.Any H/o bleeding disease Thank you for all this info

Need to do some further assessment

52 M/Dysphagia x 6 wks ----5 mins H



D/d: 1.Oesophageal Ca 2.Scleroderma 3. O.Stricture 4.O. 5.DES 6.web/Ring 7.HIV

FIRST CLARIFY: If difficulty to initiate swallowing or food coming out from nose ---- Neuro Sx/Stroke/MS Pain on swallowing ------ AIDS/CMV/Ca/Decreased immunity/Leukemia If food gets stuck -> Can you show where it gets stuck?

ONSET:How did it start? COURSE: Intermittent /progressive Intermittent for both solids & liqds ----> SPASM Intermittent for only SOLIDS---------------> Oesophageal web/ring check by endoscopy Progressive: Starts with fluid & Solids later ------>Achalasia & Scleroderma Progressive: Starts with solids & later liquids ------> M/Canical obstruction: Ca Here initially you could flush it down with water, but unable to do so now

ASSOC Sx:

N/Vx Repeated chest infections Chest pain/Tightness in chest Do you bring up undigested food? Cough Change in voice GI Sx: Abd pain/Abd distension Change in bowel pattern Any blood in stool or vomit? CONST Sx: Fever/ Night sweats/Change in appetite/Chills /Lumps & bumps If wt loss,how much Wt loss over how long? Tiredness *Mets: Liver: Yellow discoloration of skin/Dark urine & pale stools

RISK FCTS: I’m going to ask you a few qns to reach the diagnosis: 1.Any H/o heart burn? 2.Have you ever been diagnosed with a condt called GERD?----If Yes:

How long ago?

Did you seek medical attention? Was an endoscopy performed (A tube with a camera put down your food pipe to view) 3.Were you ever diagnosed with a condt called: Barret’s Oesophagus? 4.Do you smoke?/Drink alcohol? 5.FH of Oesophageal Ca 6.H/o swallowing acid or alkalies 7.H/o Chest radiation 8.H/o Achalasia 9.Any skin tightness 10.Change in color of digits when exposed to hot or cold enviorenments 11.CNS: H/o stroke/weakness H/o DM H/o HIV

Chest Pain 45 M x 6 wks



GERD ONSET: When did you first notice it? How did it start? What were you doing at that time? Course: 1.Is it the same intensity it was at the beginning? 2.Is it increasing in intensity? 3.Is it decreasing in intensity 4.Is the frequency increasing or decreasing or same? Duration: Foe how long now you’ve the pain? POSITION: Can you tell me exactly where it hurts you?

Quality

Can you describe the nature of your pain? Burning,Tightnes.... Radiation:

Does it move anywhere else in your body? To the (L) arm,Jaw,Neck,Back? S

everity: On a scale of 1 –10 ...... How has this pain affected your life? Time Does it occur at a particular time? Does it awaken you at night? Aggravating fcts: 1.Exercise/Stress 2.Food: (peppermint,fatty food,Citrus fruit) 3.Tobacco 4.Alcohol 5.Hot or cold food Relieving fcts: 1.Antacid 2.Elevation of head end of bed Assoc Fcts: Do you have 1.Heart burn 2.Acid reflux 3.Difficulty swallowing 4.Dark stools?

5.Cough 6.Hoarse voice 7.Sore throath 8.Wheezing 9.Dental problems (dental erosions)

10.Palpitations 11.SOB/PND/Orthopnea

12.Constitutional Symptoms: 13.Loss of appetite & Wt loss 14.Fever & Chills 15.Lumps & bumps 16.Lupus To gain more insight into your condition, I need to ask you some details about your life: Do you smoke Drink Alcohol *** ? Recreational drugs? Do you eat a lot of fatty foods? How soon afer dinner do you go to bed?

PAST Med H 1.Are you on any medication/ 2.Do you take Aspirin or any pain relievers or any OTC products? 3.Is there any herbal medication you’re on? 4.Are you allergic to anything? 5.Have you ever been diagnosed to have a High BP or high BSL? 6.Have you ever had a heart attack or stroke? 7.Were you ever hospitalized? 8.Did you ever undergo any surgical procedure?

FAMILY History Social History

MGment: Nonpharmacologic Choices •Dietary modifications (avoid chocolate, caffeine, acidic citrus juices, large fatty meals) •Weight loss if obese (BMI > 25 to 30 kg/m2) •No snacks within 3 hours before bedtime •No lying down after meals •Reduce alcohol intake •Elevate legs under the head of the bed on 10 to 15 cm blocks •Stop smoking •Avoid tight clothing

Pharmacologic Choices

When possible, eliminate drugs that impair esophageal motility and lower esophageal sphincter tone (e.g., calcium channel blockers, theophylline, tricyclic antidepressants, beta-blockers, anticholinergic agents).

6th Feb GU If CC Urinary Sx: I.Obstruction II.Irritation III.Urinary changes OSTRUCTION 4 qns: 1.Difficulty initiating urine ----->Do U need to strain? 2.Did you notice change in stream? 3.Dribbling? 4.After passing urine, do you still need to pass more? IRRITATION: 1.How many time do you need to go to Wash room: Now,Before At Night? 2.Does it affect your sleep? 3.Do you feel you need to rush to WC 4.Are you able to make it in time? 5.Have you ever lost control? 6.Burning sensation 7.Flank pain 8.Fever URINE CHANGES: COCA + Bld Consistency,remember: 1.Frothy urine 2.Cloudy urine 3.Not clear urine

67 M ER reten48 hrs/Colleague passed F Catheter & got 1.2 L urine



As I understand, you’re here today because you’d difficulty in passing urine since 24 hrs.& one of my colleagues has passed a Foley catheter & drained 1.2L urine. HOW DO YOU FEEL RIGHT NOW? I’m glad to know you’re better If Pt c/o pain: Bear with me few minutes as soon as I finish with asking you a few Qns I will deal with it. Can you tell me about it since it all began?

OCD -------- U V

How many times did you try to void? Were you able to pass any amt? Is it the first time/Can be first time to this extent Recently have you noticed any changes in your urine?you.g: Do U need to rush? When did it first start?

From that time till now, is it Increasing/Decreasing? • Sx of Obstruction: 1.Difficulty initiating urine ----->Do U need to strain? 2.Did U notice change in stream? 3.Dribbling? 4.After passing urine,do U still need to pass more? EMPATHY •Sx of irritation: 1.How many times do U need to go to Wash room: Now, Before At Night? Does it affect your sleep? 2.Do U feel U need to rush to WC Are you able to make it in time? Have you ever lost control? 3.Burning sensation 4.Flank pain 5.Fever •Urine changes: COCA + Bld Ask if H/o passing stones in urine C Sx: ASx: Trauma to back:Back pain Sx of GU: asked in earlier Qns Mets to Liver: Sx of Liver Disease Mets to lung: Cough/Haemoptysis Mets to CNS:

RISK FCTS: 1.Have you ever been screened or diagnosed as prostrate disease? 2.Have you ever done the blood test for PSA 3.FH of Ca Prostrate: Who & at what age? 4.Do you smoke 5.Take alcohol 6. How is your diet?

D/D: 1.Are you on any medications? 2.Do you take psychiatric medications 3.Meds for Glaucoma? 4.H/O Stroke 5.H/o Urethritis 6.Sx of renal failure: Puffy face, swollen ankles

PMH: Since this is the first time I’m seeing you, I need to ask you some qns regarding your Past Medical History: Do you have DM/HTN Hospitalized or had any surgeries? SOCIAL H:

67 M brought in by daughter,as she is concerened that he is not himself



Greeting: As I understand .......... Whenever a pt is brought in by someone always ask:DO U AGREE? If Yes:...I’m glad you’re here as we can find a working solution If NO: I would appreciate that you’re here just to make you daughter happy, I promise you I will be as fast as I can.

Tell me more about the concern: She is worried that I’m not going out as I used to before. Do you stay at home? I’m not going away to far places or out with my friends When did this happen? Do you share her concern? My daughter overreacts I’m Glad you’re here What prevents you from going out? GIVE CONFIDENTIALITY I wet myself When How many times? How did you react at that time?

The go to Urine History: Obstructn/Iritation/Urine

If Pt does not divulge, Go to Geriatric History: 1.What Medications?do you take & ask to see list or bag of meds Do you take sleeping pills (specifically ask for that as it affects memory & gait)OTC/Herbal products 2.Screen for Mood & Memory 3.Vision & Hearing/Balance & Falls 4.Urine: Retention in males & Incontinence in females 5.Sleep: How many hours 5.1 When do you go to bed? 5.2 Do you get up frequently? Follow event.......... If still refuses to talk,do review of Sx

67 M Dark urine x 1 week (H x 5 min)



D/D: 1.Bleeding/SE of warfarin 2.PSGN 3.Stone 4.Nephrotic syndrome 5.Renal or bladder Ca 6.Trauma 7.Berger’s disease 8.Infection

If CC is Dark Urine, make sure it is haematuria & not Jaundice What do you actually mean? Dark like Tea/Cola or Red? OCD O:Sudden/gradual C: from that time till now,is it: Off & on or continous/Same D: Has it ever happened before? P Does it occur at the: 1. Beginning of stream?(Urethra) 2. End of the stream? (bladder) 3. Whole of the stream? (Kidney) V: Urine changes:COCA + Bld Consistency,remember: 1.Frothy urine 2.Cloudy urine 3.Not clear urine Obstrn 1.Difficulty initiating urine ----->Do you need to strain? 2.Did you notice change in stream? 3.Dribbling? 4.After passing urine, do you still need to pass more? Irritation: 1.How many time do you need to go to Wash room: Now,Before At Night? 2.Does it affect your sleep? 3.Do you feel you need to rush to WC 4.Are you able to make it in time? 5.Have you ever lost control? 6.Burning sensation 7.Flank pain 8.Fever

C Sx: ASx: 1.Back trauma 2.H/O recent Sore throat or skin infection If yes to sore throat: When was that/Was there swelling of feet/Puffy face? 3.H/o bleeding tendencies or blood thinners If Yes to blood thinners: Which one/Why/How long/How much do you take/When was last F/U/what was your last INR/What is the target/Any new medications/Any antibiotics? 4.Did you notice bleeding from any other sites? Gums/Nose/Malena/CNS:Numbness,weakness,difficulty finding words ...... 5.H/o stones

Neuropathic Pain



Neurologic Disorders: Neuropathic Pain

Table 1: Types of Neuropathic Pain Peripheral Neuropathic Pain Central Neuropathic Pain • Nerve root pain • Central post-stroke pain • Carpal tunnel syndrome • Spinal cord injury pain • Trigeminal neuralgia • Brain injury • Postherpetic neuralgia • Multiple sclerosis • Incisional neuralgia • Syringomyelia • Nerve trauma (causalgia) • Phantom limb pain Investigations History with attention to: otemporal profile and characteristics of the pain ofunctional status, mood, quality of life, insomnia, sexual function, previous and current treatments, especially concurrent medications opresent or past chemical dependency, especially if opioids are considered • Physical examination: odetermine areas of sensory loss (hypoesthesia) and skin sensitivity characteristic of neuropathic pain determine other neurologic findings that might indicate a progressive lesion requiring imaging and surgery odetermine concurrent conditions that contribute to the pain problem, e.g., concomitant muscular pain and psychological factors • Other investigations: oimaging with CT or MR scanning if a space-occupying lesion is suspected o electromyography odiagnostic sympathetic blockade if complex regional pain syndrome is suspected o although there is no established therapeutic range, monitoring serum levels of tricyclic antidepressants (TCAs) and antiepileptic drugs may help to assess adherence and guide dosage Guideline for Use of Opioids in Chronic Nonmalignant Pain •Consider after other reasonable therapies have failed. •Perform a complete pain and psychosocial history, physical examination and appropriate diagnostic tests. A history of substance abuse, tension-type headaches, frequent migraine headache, muscular pain (myofascial pain, fibromyalgia) or pain that appears to be largely determined by psychologic factors is a relative contraindication to the use of opioid therapy. •A single physician/prescriber/pharmacy is optimal. The prescriber may choose to set up a contract with the patient. The agreement should specify the drug regimen, possible side effects, the functional restoration program and that violations may result in termination of opioid therapy. •The opioid analgesic of choice should be administered around the clock and may include a provision of “rescue doses” for breakthrough pain. Controlled-release preparations include morphine, oxycodone, hydromorphone, tramadol and transdermal fentanyl. Avoid meperidine primarily because of accumulation of its excitotoxic metabolite normeperidine. Codeine is a poor analgesic for moderate to severe pain because it has to be metabolized to morphine. Drug administration should include a titration phase to minimize side effects. If a graded analgesic response to incremental doses is not observed, the patient may not be opioidresponsive, and opioid treatment should probably be terminated. •The patient should be seen monthly or more often for the first few months and every 2–3 months thereafter. At each visit 1.assess pain relief (0–10 scale), 2.mood, 3.side effects, 4.quality of life, 5.adherence to functional goals and 6. presence of drug-related behaviour. Optimally, affix a copy of the prescription and drug therapy flow sheet to the medical record. •The goal of opioid therapy is to make the pain tolerable. For some patients with chronic noncancer pain (e.g., postherpetic neuralgia), the administration of an opioid analgesic can mean the difference between bearable and unbearable pain. Therapeutic Tips

•Two to three months constitutes a reasonable trial of medication for neuropathic pain. •While patients frequently say they have used amitriptyline or carbamazepine or other agents, these drugs have often been used in too high or too low a dose and for too short a period of time. It is useful to re-institute these drugs to evaluate their effectiveness when used appropriately: start low, go slow, increase dose until relief of symptoms or side effects occur and treat side effects when possible. •Be sure the patient understands the goals of therapy: reduction in pain from moderate or severe to mild, at the price of some side effects that may be tolerable or treatable. •Use a pain assessment tool, such as a scale of 0–10 where 0 is no pain and 10 the worst pain imaginable, to evaluate pain with and without activity, and before and after medication. •As a matter of course, prescribe an artificial saliva mouth spray with TCAs and a stool softener with TCAs or opioids. •Use controlled-release formulations of carbamazepine and opioids •It may be possible to reduce or gradually withdraw medication after initial control of pain and a period of relief of 1–3 months (pain such as postherpetic neuralgia may resolve spontaneously and trigeminal neuralgia may go into remission). Gradual reduction is important to avoid withdrawal symptoms. •Always consider combining pharmacotherapy with appropriate psychological and physical measures. •Try different drugs within a class (e.g., a TCA or a gabapentinoid such as gabapentin or pregabalin), drugs of different classes and combination therapy (polypharmacy) for a possible additive or synergistic effect; do not combine TCAs with SNRIs. •If opioids are used, guidelines are important and should be worked through with the patient. •A trial and error approach of scientifically unproven treatments is reasonable if standard therapy fails. •Repeated visits can provide important psychological support and hope for desperate patients as trial and error approaches are utilized. •If chronic neuropathic pain is being managed in general practice, semi-annual or annual visits to a pain specialist (where available) help provide support to the family practitioner for contentious approaches such as opioids, and offer the chance of a novel therapy for the patient

HEADACHE



Dd: 1.Tension H 2.Cluster H 3.Migraine 4.Temporal A 5.Cervical Spondylitis 6.Meningitis 7.SOL 8.SAH 9.Depression 10.Spousal abuse

Red Flags for Serious Headache 1. Age of onset Middle-aged to elderly patient 2. Type of onset Severe and abrupt 3. Temporal sequence Progressive severity or increased frequency 4. Pattern Significant change in headache pattern 5. Neurologic signs Stiff neck, focal signs, reduced consciousness 6. Systemic signs Fever, appears sick, abnormal examination Caution: If headache does not fit typical pattern, a serious diagnosis can be missed. ***** Chronic Daily Headache & Medication overuse Headache

Chronic headache occurs daily or almost daily for 15 days per month, for 6 months or longer. The most common causes of these headaches are transformed migraine and chronic tension-type headache. In the former there is history of migraine attacks and over several years the migraine attacks become more frequent. Soon the migraine characteristics give way to chronic daily headache with a daily or near-daily background headache that often resembles a typical “tension-type headache.” People with chronic tension-type headache may have no history of distinct migraine. Patients with these disorders frequently use excessive amounts of abortive agents, including ergots, acetaminophen, ASA and opioid analgesics. They can have rebound headaches as a result of medication-overuse, while some may have symptoms of depression or other psychological comorbidities. Rebound headaches can also occur with the overuse of triptans. Most will improve in days or a few weeks with the discontinuation of these medications, especially mixed analgesics. Generally, simple analgesics should be used less than 15 days per month in primary headache disorders such as migraine or tension-type headache or they will lead to the development of medication-overuse headache and chronic daily headache. Further, if chronic daily headache develops, other useful abortive and prophylactic medications usually have less efficacy. Management includes recognition of these disorders, tapering and stopping the offending agent(s), and starting a prophylactic medication such as amitriptyline or another agent listed in. During withdrawal, particularly in patients with transformed migraine, use abortive agents such as DHE or a triptan for treatment of the migraine headaches that emerge. Short-term admission to hospital may be required to use the Raskin protocol (using DHE) and give support. If psychological comorbidities such as depression are present, they must be managed and treated. Consider referral to a multidisciplinary pain management clinic for cases failing to respond to therapy. Therapeutic Tips •Give abortive treatment, without exceeding recommended dosages, as soon as possible. •Use simple analgesics less than 15 days per month, and ergots, triptans, opioids or analgesic combinations less than 10 days per month. •A calendar or diary of headaches is useful in follow-up assessment. •Keep a record of medications (usefulness, dosage and side effects). •If migraine that does not respond adequately to symptomatic therapy occurs more than 3–4 times per month, try prophylactic medications for several months and then discontinue if possible, to assess ongoing need.2 •Different medications may need to be tried, including different members of the same class, such as triptans. •Follow-up is most important in managing chronic headache. •Reassurance and explanation are most important to the patient in the long term. •Always offer hope to patients with chronic headache even if no cure is available; most primary headaches can be controlled.

ACUTE HA x 10 days: 67M in ER



HISTORY: OCD PQRSTUV Onset: Sudden Vs Gradual Course: •All the time •Is it increasing or decreasing or is it the same? •VARIATION: Did you notice any variation? •Is it the same throughout the day •Does it awaken you at night? (EMPATHIZE++++) Duration: •How long the whole disorder •How long each attack • How frequent: off & on Posn: •Unilareral/Bilateral • Where is it exactly? •Does the part where it hurts is tender (Temporal Arteritis) & do you feel like a cord-like structure there? Quality: •Throbbing •Burning •Tightness/Pressure • Ice pick like Radiation? front,side,back of head,or in the eyes,ears or throats? Severity: On a scale of 1 – 10 Can you say It is the worst HA of your life? Timing Triggers:(not when single episode) U: Qns for empathy** • How has it affected U in your daily life? • How r U coping with it? • How do U feel abt it? • What r your expectations from today’s visit?

V= deja Vu Has it happened before? Aggravating factors: •Eating (Jaw claudication) •Bending forwards/Coughing/Lifting/Lying down (Inc ICP) •Lights/Certain foods etc (Migraine) •Eyestrain (vision correction) • Alcohol (cluster H) Alleviating fcts: Did you try any meds & were they helpful? Assoc.Symptoms: In addition to your headache did you notice any other symptoms: (Try & do constitutional sx first as you may forget them) Fever/Neck pain/Photophobia/Skin rash/Ear infection NEURO Screening: 1.Vision changes: What type of problem? 2.Hearing abnormalities 3.Difficulty swallowing 4.Weakness/Numbness 5.Difficulty finding words 6.Difficulty in balance or repeated falls 7.Changes n bowel/Urine Loss of bladder control 8.LOC 9.H/o Seizure

MOOD Changes MEMORY problem Changes in CONCENTRATION Has anyone told you that you’ve ben acting strangely?

MSK Screening Is there pain in your joints For how long? Can you raise your arms above your head?

H/O INJURY: To head Did you have a fall & hurt your head?

EXTRACRANIAL: EYE: Did you notice any redness or need eyeglasses? Sinusitis: Facial pain/flu Throath pain Dental pain

RISK FCTS: Do you smoke Take EtOh Take recreational drugs?

PMH: Have you taken pain killers,if +ve: How much & for how long (rebound HA) Did you take any OTC or herbal meds? Are you allergic to anything? Have you ever been diagnosed with HTN/DM/Stroke/MI/Ca? Were you ever hospitalized or underwent Surgery? FAMILY H: HTN/DM/Stroke/MI SOCIAL H: Who lives with you? How do you support yourself financially? DIAGNOSIS: Temporal Arteritis

24 M/HA 6 wks Office 10 mins H & C



Primary Headache Secondary Headache Type % Type % Migraine 16 Systemic infection 63 Tension-type 69 Head injury 4 Cluster 0.1 Vascular disorders 1 Idiopathic stabbing 2 Subarachnoid hemorrhage

Exertional 1 Brain tumor 0.1 Cluster headache is a rare form of primary headache The pain is deep, usually retroorbital, often excruciating in intensity, nonfluctuating, and explosive in quality. A core feature of cluster headache is periodicity. At least one of the daily attacks of pain recurs at about the same hour each day for the duration of a cluster bout. The typical cluster headache patient has daily bouts of one to two attacks of relatively shortduration unilateral pain for 8–10 weeks a year; this is usually followed by a pain-free interval that averages 1 year. Cluster headache is characterized as chronic when there is no period of sustained remission. Patients are generally perfectly well between episodes. Onset is nocturnal in about 50% of patients, and men are affected three times more often than women. Patients with cluster headache tend to move about during attacks, pacing, rocking, or rubbing their head for relief; some may even become aggressive during attacks. This is in sharp contrast to patients with migraine, who prefer to remain motionless during attacks. Cluster headache is associated with ipsilateral symptoms of cranial parasympathetic autonomic activation: conjunctival injection or lacrimation, rhinorrhea or nasal congestion, or cranial sympathetic dysfunction such as ptosis.

OCD ONSET: If pt says this time was worst: Ask Prev episode,if present: 1.How long ago? 2.Did you seek medical attention then? 3.What was the diagnosis? 4.What Rx was given? 5.Is this current HA different from from the previous one? NOW GO to THE CURRENT HA. Finish with the current HA & can go back to previous HA ONSET:Gradual/Intermittent COURSE: Inc/Dec/Same DURATION: How Often? How long does each episode last? Everyday,few hrs,wkends longer& awaken at night? POSN QUALITY: R S T U V AlLEVIATING FCTS: Sleep/Pacing/Dark room/Lying down

AGGRAVATING FCTS:

•Flashing lights •Lack of sleep •Certain food •Alcohol (Cluster ) CONSTITUTIONAL Sx Fever/chills/N Sweats/Loss of appetite & loss of wt/Lumps or bumps anywhere TRAUMA: RISK FCTS: Are you under stress? How do you handle stress? Do you Smoke?...... Do you take Alcohol: How much How long Why?? Have you used recreational drugs? How is your MOOD? Any chance that you may be depressed? *MI PASS ECG Mood: Interest Psychomotor retardation Appetite Sleep Suicidal ideation Energy Concentration Guilt If M& I are +ve Look for depression

PMH: Are you taking any meds?/OTC/Herbal products? Were you ever Diagnosed with HTN/DM/Ca Were you ever hospitalized or had surgery? FH: SOCIAL HISTORY: Who lives with you? How do you support yourself financially?

Acute Attack Treatment Cluster headache attacks peak rapidly, and thus a treatment with quick onset is required. Many patients with acute cluster headache respond very well to oxygen inhalation. This should be given as 100% oxygen at 10–12 L/min for 15–20 min. Sumatriptan 6 mg subcutaneously is rapid in onset and will usually shorten an attack to 10–15 min;. Sumatriptan (20 mg) and zolmitriptan (5 mg) nasal sprays are both effective in acute cluster headache, offering a useful option for patients who may not wish to self-inject daily. Oral sumatriptan is not effective for prevention or for acute treatment of cluster headache. Preventive Treatments The choice of a preventive treatment in cluster headache depends in part on the length of the bout. Patients with long bouts or those with chronic cluster headache require medicines that are safe when taken for long periods. For patients with relatively short bouts, limited courses of oral glucocorticoids or methysergide (not available in the United States) can be very useful. A 10-day course of prednisone, beginning at 60 mg daily for 7 days and followed by a rapid taper, may interrupt the pain bout for many patients. When ergotamine (1–2 mg) is used, it is most effective when given 1–2 h before an expected attack. Patients who use ergotamine daily must be educated regarding the early symptoms of ergotism, which may include vomiting, numbness, tingling, pain, and cyanosis of the limbs; a weekly limit of 14 mg should be adhered to. Lithium (600–900 mg qd) appears to be particularly useful for the chronic form of the disorder. Table 15-9 Preventive Management of Cluster

Headache

Short-Term Prevention Long-Term Prevention Episodic Cluster Headache Episodic Cluster Chronic Cluster Headache & Prolonged

Headache Prednisone 1 mg/kg up to 60 mg qd, tapering over 21 days Verapamil 160–960 mg/d Methysergide 3–12 mg/d Lithium 400–800 mg/d Verapamil 160–960 mg/d Methysergide 3–12 mg/d Greater occipital nerve injection Topiramatea 100–400 mg/d

Gabapentina 1200–3600 mg/d

35F HAx 6 wks H & C



Can you tell me abt it since you first noticed it? I’m glad you came in today,do you have the HA now?Any particular reason as to why you came in today? OCD Empathize+++ PQRSTUV CONSTITUTIONAL Sx Local Sx: RISK FCTS: Smoking/alcohol/recreational drugs PMH: •Are you on any medications • Are you on the Contraceptive Pill? •Was it changed recently? •Did you notice any relation to the HA & the Pill? •Any OTC/Herbal meds? •HTN?DM?MI?STROKE?CA? Any hospitalizations or Surgery? FH: Similar HA in any one of your family members? FH of HTN/DM/Stroke/MI SOCIAL H: Stress in your life? Who lives with you? Look out for Domestic Violence.... How do you support yourself financially? COUNSELLING: Migraine can be related to the pill Disct the OC or change the particular pill & switch to another form of pill or contraception like IUCD or barrier method o avoid triggers, especially in migraine, e.g., too much or too little sleep, irregular meals, lack of regular exercise, extremes of stress or relaxation, known dietary triggers o apply ice; sleep or rest in a dark, noise-free room DIAGNOSIS:MIGRAINE

45 M HAx 4 wks



OCD PQRSTUV This scenario Pt has typically gets HA at work,better at wkends & when he is drivng home. Alert to possibility to exposure to something at work. On H/o : •What sort of Job, he was a forklift operator. •Ask which sort of Environment he works whether it is: 1.Open or closed 2.Operated by electricity or gas 3.Presence or absence of ventilation 4.Presence of Carbon monoxide alarm,whether it has ben checked 5.If anybody else in the work place has a similar HA

40F/Looks older Weakness (R) arm x 6 hrs History x 5 mins & review of Sx



D/d: Vitamin D Vascular:Stroke/ICH/TIA INFECTION: Abscess/Meningitis/Encephalitis Traumatic: Head Injury Autoimmune:Vasculitis Metabolic: electrolyte abnormalities/Hyperthyroidism/Uremia Idiopathic:Syncope/MS Neoplastic: Mets or Pirmary Brain T Drugs: EtOH/Cocaine/Phencyclidene/Amphetamine

OCD: O: Sudden/Gradual What were you doing at that time it occured C: Is it getting worse? D:

PQRST UV Quality of defeciet: Sensory/Movt/Power 1.How weak is it? 2.Can you move at all? 3.Partially weak? U:How has it affected your life? (ADLs) Gross motor:(Reaching shelves/Opening doors) Fine Motor:Buttoning shirt/using keys/writing V: Have you had such episodes previously? OTHER LIMB: what abt (R) Leg/(L) Arm & (L) Leg

Assoc Sx: Local Sx: •Parasthesias/Pain •Calf Pain/Swelling •Recent travel/Immobilization CNS: HA/Dizziness/LOC/Visual disturbances (amaroux Fugax)/Slurred speech CVS: Palpitations/Chest pain CONST Sx: Fever/Chills/wt loss/Lumps & Bumps Trauma: or injury Bladder: any urinary problems (R/O MSclerosis) RISK FCTS: Smoke/Alcohol Was your blood ever checked for cholesterol & Sugar? ....... When/if on any Rx ......... OC DM/HTN/Stroke/Ca/MI Do you have a form of regular exercise?

PMH: •Are you on any Meds/OTC/Herbal products (particularly Asa/Warfarin/Blood thinners) •Do you have any allergies •Were you ever hospitalized or had any Surgeries? •Do you have any Peptic Ulcers

FH: Does anybody else in Family have such a condition HTN/DM/Stroke?MI SOCIAL H: Who lives with you? How do you support yourself financially?

Alteplase in Acute Ischemic Stroke: Treatment Criteria Treatment criteria 1.Ischemic stroke in a patient ≥ 18 years 2.Stroke onset > 1 h and ≤ 4.5 h before alteplase administration 3.Stroke deficit that is disabling or measurable on the NIH Stroke Scale 4.No intracranial hemorrhage on CT or MRI scan

Exclusion criteria 1.Time of stroke onset unknown or > 4.5 h 2.Any hemorrhage on brain CT or MRI scan 3.Symptoms suggestive of subarachnoid hemorrhage 4.CT or MRI signs of acute hemispheric infarction involving more than 1/3 of the MCA 5.History of intracranial hemorrhage 6.Stroke or serious head or spinal trauma within the preceding 3 mo 7.Seizure at stroke onset 8.Systolic blood pressure ≥ 185 mm Hg or diastolic blood pressure ≥ 110 mm Hg or aggressive treatment (intravenous medication) necessary to reduce blood pressure to these limits 9.Recent major surgery 10.Arterial puncture at a noncompressible site within the previous 7 days 11.Elevated activated partial thromboplastin time 12.International normalized ratio > 1.7 13.Platelet count < 100 × 109/L 14.Blood glucose concentration < 2.7 or > 22 mmol/L 15.Any other condition that could increase the risk of hemorrhage after alteplase administration

Alteplase in Acute Ischemic Stroke: Monitoring5 Blood Pressure and Neurological Signs •Baseline, then Q15min × 2 h after starting alteplase •Then Q30min × 6 h •Then Q1H until 24 h after starting alteplase •Call MD if the systolic BP is > 180 mm Hg or if the diastolic BP is > 110 mm Hg on 2 or more occasions taken 5–10 min apart •Stop the infusion, obtain emergency CT scan and notify MD if there is neurologic deterioration, severe headache, or new onset of nausea or vomiting Blood Glucose •Call MD if glucose > 12 mmol/L Lines and Tubes •Delay placement of nasogastric tubes, indwelling catheters or intra-arterial pressure catheters Medications •No ASA, ticlopidine, clopidogrel, heparin or warfarin for 24 h •Acetaminophen 650 mg po or pr Q4H if body temperature is ≥ 38°C or for analgesia •O2 via nasal prongs or face mask to keep O2 saturation > 90% •After the alteplase infusion is completed, continue iv normal saline (with or without KCl) Investigations • CT brain scan after 24 h Carotid endarterectomy (CEA)2 Patients with carotid territory transient ischemic attack or nondisabling stroke and ipsilateral 70– 95% internal carotid artery stenosis should be offered carotid endarterectomy within 2 weeks of the incident transient ischemic attack or stroke unless contraindicated. CEA is also appropriate for selected patients with moderate (50–69%) symptomatic stenosis. These patients should be evaluated by a physician with expertise in stroke management. Carotid stenting may be considered for patients who are not CEA candidates for technical, anatomical or medical reasons. Antiplatelet therapy

•If intracranial hemorrhage is excluded by CT scan, but alteplase is not indicated, give ASA 160 mg immediately. This is followed by ASA 80–325 mg daily. •When alteplase is used, wait until intracranial hemorrhage is excluded by CT scan 24 hours later and give ASA 160 mg once. This is followed by ASA 80–325 mg daily. •Administer ASA as a suppository or via nasogastric tube to dysphagic patients. Use enteric-coated formulation for patients who can swallow. No evidence supports the use of ASA doses greater than 325 mg/day for secondary stroke prevention. The GI side effects of ASA are dose related. •For patients who were taking ASA prior to their stroke, consider other antiplatelet agents, such as clopidogrel 75 mg daily or a combination of ASA and sustained-release dipyridamole 25/200 mg twice daily, although these regimens have not been tested in acute stroke. •The combination of ASA and clopidogrel is not recommended for long-term secondary stroke prevention. Anticoagulant therapy •Immediate systemic anticoagulation with unfractionated heparin, low molecular weight heparin, heparinoids or specific thrombin inhibitors is not recommended in the setting of acute ischemic stroke, not even for patients in atrial fibrillation (AF), because there is no evidence of short- or long-term benefit. Specifically, reduction in early recurrent ischemic stroke is completely offset by an increase in major intracranial and extracranial bleeding.18 •ASA is as effective as warfarin for secondary stroke prevention in patients in normal sinus rhythm, and does not require laboratory monitoring. •For patients in AF, use warfarin at a dose to maintain the INR in the range 2.0 to 3.0, provided there are no contraindications to anticoagulation. For patients who cannot take warfarin, use enteric-coated ASA 80–325 mg daily. •The best time to initiate anticoagulant therapy is unclear. For patients with minor strokes, start warfarin as soon as intracranial hemorrhage has been excluded by CT scan. For patients with major strokes, delay warfarin until a CT scan done about a week or two after the stroke has excluded hemorrhagic transformation of the infarct. Blood pressure lowering treatment Randomized controlled trials have not defined the optimal time to initiate blood pressure lowering therapy after stroke.19 Oral blood pressure lowering treatment should be initiated (or modified) prior to discharge from hospital in patients whose blood pressure is ≥ 140/90.

IV. Restore Function of the Individual •Outcomes are optimized by care on a stroke unit provided by a coordinated interdisciplinary team (Start rehabilitation as soon as the patient is medically stable. •Family and community supports are important for social reintegration.

Therapeutic Tips •The effectiveness of thrombolytic therapy with alteplase is exquisitely time dependent; delays of any sort should not be tolerated. A minority of patients present to hospital within the first 90 minutes of stroke onset, leaving limited time to act. Immediate contact with the patient, rapid triage, and (most importantly) staying with the patient continuously during the clinical assessment, CT scan, blood tests and consent procedures are vital in ensuring that the appropriate steps are being taken as rapidly as possible prior to alteplase administration. For example, it is not necessary to wait for hospital porters to take the patient to the CT scanner. •Determining the time of stroke onset is critical in deciding to use alteplase, but checking the clock is not a natural reaction in the setting of an acute stroke. Encourage patients and families to think of “time anchors” (e.g., what was on the radio or TV at the time, or at what point in the patient's daily routine did the symptoms first occur). •Patients with acute stroke are often unable to communicate. When possible, the next-of-kin should travel with the patient to hospital (or between hospitals if the patient is transferred) to provide collateral history and consent for treatment before the time window for intervention closes. •If the patient is referred to a tertiary care hospital, have the stat blood work (CBC, INR) drawn at the community hospital and the results faxed to the referral centre as soon as possible. •Point-of-care INR testing , if available, can provide results quickly. •Signs of infarction on a CT scan done within 4.5 hours of stroke onset are usually subtle. If the CT scan of a patient being considered for treatment with alteplase shows a very definite infarct in a location that explains the presenting clinical symptoms and signs, recheck the time of onset.

A 30 YOF with right arm weakness for 10 hours, Hx for 5m



Intro Where is your weakness? Can you still work with your hand or no? Do you have burning or tingling sensation on your hand or shoulder? How about numbness? Any problem on your right foot? Lt. arm or leg? Is it the first time? (If the patient says that she had it before than: “When was it? How long did it last? Which medication did she take?) Did you fall or lost your consciousness? Any change in your vision? Loss of vision? Double vision? Blurry vision? Any change in your hearing? Buzzing sound? Diffucult in finding words? Any change in balance? Any change in urination and bowel movement? When you bent your neck do you fill electrical shock along your spine? Do you difficult to swallow? Have you ever had dizziness, headlightedness, loss of consciousness, jerky movement, seizure? How is your mood / concentration / memory? Any change in your personality? When you touch your face do you feel any electrical shock? Uhthoff’s sign: when they get hot water or hot weather – trigger for their symptoms (especially optic neuritis). Review systems from head to toe: chest pain, heart racing, sob, cough and phlegm, abdominal pain, nausea and vomiting, joint pain, skin rash, diabetes, thyroid disease, anemia CSx RF for MS, PMHx, FMHx

PAEDS



1.Pediatrics (30) 2.Psychiatry (30) 3.Physical exam (30) 4.Management (12) 5.OBGYN ( 6.Communication Skills (10) 7.Counseling (10) 8.Medicine (CVS 15, Neu 15, Med 20)

Pediatrics Consider abuse There are no children in the room, only parents. Maternity leave – either husband or wifes.



A child 9m – chronic diarrhea



(CF, Celiac, HIV; Lactose deficien cy)

5y.o fever – take history



Skin rash – ask questions about it (distribution, relation to vfever) HSP

Son, 3y.o is coughing for 4wk and they want to renew his antibiotics



This shows there was a condition Ask What Ab,for which condt,When?. Don’t waste your time –R/O: Hyperactive airways or is it infection that has not cleared,or could be asthma.

A mother just delivers a baby who is IUGR all questions should about pregnancy and delivery



1.Reassure her, 2.Note appearance of the child 3.Note Paediatrician’s visit, 4.History of pregnancy/Obstetric History 5.Family history. In case mum was smoking,taking alcohol & drugs & asks if her fault if child has IUGR Don’t reproach her – it is NOT her mistake. It is a multi-factorial condition.Can be due to various causes,some genetic,pregnancy,related to baby Because safe levels of smoking,drugs & alcohol not known, We always recommend not to smoke or drink for futurepregnancies.

Parents are concerned that their child is not growing enough



[AGEx2+8] What his weight in birth. 14m 8Kg (birth weight 3.5Kg). He is underweight.

CC OCD COCA-B AA ASx PMHx SHx 0-6m: BINDE Birth – Pregnancy: Was it a planned pregnancy? 1.Did you have any regular follow-up? 2.Did you have any US? Was it normal or not? 3.During your pregnancy did you have any fever or skin rash? 4.Any contact with sick person or cats? 5.Any medication/smoking/drugs/alcohol? 6.Screened for HIV/Syphilis/GBS/Hepatitis B? Blood group? Birth – Delivery: 1.Was it in term or not? 2.What is the route? (Cs/NVD) 3.How long it took? (18hr is normal for primi, 12hr for multi), 4.Early gush of water? 5.Any need for augmentation? 6.What was the APGAR score? 7.Did the baby cry immediately? 8.Did your baby need any special attention? 9.Any bulging or bruising in his body? 10.When were you sent home?(C/S 3d, V/D – 1d). 11.After delivery did you have any fever/vaginal discharge/any medication? 12.Were you told that your baby had any congenital deformity?

Immunization – if he says that the child is not immunized you have to inquire for the reason. If he is not vaccinated because the parent is busy – look for child abuse RED FLAG.Ask wt & milestones If it is due to religion believe – you don’t have to ask more. Otherwise – ask about nutrition.

Nutrition – WEIGHT: 1.What his weight today, 2.Weight at birth, 3.Highest weight, Growth chart. X (birth), 5m-2x, 1y-3x, 2y-4x. Weight: Agex2+8 H (birth, about 50cm), 1y-1y, 2y-1.75H (half of his adult height), 4y-3.5H HC (at birth): 35cm What do you FEED your baby If formula: – When did you start the formula If B Fed at all Did you consider B feeding? what type of formula do you use? How do you prepare it? Was there any changes in the feeding? Did you add any solid food or supplements (any fortified serials or iron) do you feed him with any bread, solid food – when started the diarrhea (before the solid food or after?)

Development – At the end 1y they use words, 2y – two words at one sentence, 3y – 3words in one sentence; 4y – speak normally. Gross motor: role – 4m, seat- 6m, crowling – 9m, standing – 1y, climbing upstairs – 18y, riding bicycle – 3y

Environment – with whom do you live at home? Any other children? Relation between your child and other households? Who spends most of the time with the child? Financially how do you support yourself? Do you live in your own house? Do you have basement in your house? Anybody drinks or uses drugs? Building – basement (mold) and Old houses (lead poisoning). 6-12m: School Performance: comparing the grades between now and previous. >12-14 yrs: HEAADDSSS Home: with whom do you live? Education: Which grade? How are your marks? What do you want to be? Recent drop in grades? Activities: Any hobbies? (in case of epilepsy – ask for the risky activities) Alcohol: do you smoke, drink, (a lot of people of your age might experiment with drugs? How about you?), Smoking Diet: do you have any special diet? Drugs: have you ever tried recreational drugs? Smoke Sexual: are you in relationship? Suicide: how is your mood?

Questions for dehydration: Does baby have tears when crying? How many times you pee? How many times you change his diapers?

5 Day old infant with yellow discoloration since he was 2 days old



A mother who is after 5days from deliver (if she uses the word jaundice; what do you mean be that?). Is it early in the second day is it pathological. Late in the second day – it has no value. Make sure that the baby is stable – Red flags: 1.High pitched crying, 2.Poor feeding & Poor sucking 3.Floppy baby, 4.If above three are present, it is a problem, decide to reassure her or tell her you’ve to do a physical exam& admit If you have to take history and counsel ------>Reassuarence Only history-------->Pathological m/p it is not physiology

What is the name of your child? (He is yellow) Good you are here; I hope you can reassure you at the end. OCD Tell me more about it since the moment it started O: Is it early in the second day is it pathological. Late in the second day – it has no value C: D: Where did you notice it? Is it spreading? Did it reaches the legs? Is it getting darker? In addition to it did you notice any dark urine? Pale stool (in bliary atresia – pale stool from the beginning?) ASx: INFECTION: In addition to that did you notice any fever, cough, discharge from ear,discharge diarrhea, vomiting, foul smell urine, is he crying, is he floppy, is he sucking well, (RED FLAGS) Rash, Dehydration: how many diapers did he change, any tears Transition: I am going to ask you some questions to see if any conditions cause this issue back to your pregnancy FHx: of liver disease and blood disease. If she are concerned – why you are concerned (will he be mental retarded).

Child crying for the last 10d, 6w old, Counsel the father



A child who’s with infantile colic. How do you feel when your child is crying. Crying child could be colic,screen for abuse,see how parents handle it The crying might cause abuse

Weight, dehydration, Start to observe the body language of the father. OCD O; At that time was there any illness,like fever,runny nose C; Off & On/all the time Every single day,every day,how many days/week also “is he crying during the night?” – how does it affect you and your wife?) Aggravating FCts: Any chance he is hungry? Any chance he is wet & neds a diaper change? Diaper rash? Any chance he is too hot or cold? Alleviating Sx: Do you soothe him/hug him/carry him & walk/take hime for a ride/listen to music? Do you burp him/rock him/Skhe him? If Yes: How many times? When was the last time? What happens to him when you shake him? Does he stop crying? Does he pass out? (Children at this age cannot express their discomfort& only means of communication is by crying“I am going to ask some questions to see if there is any reason for this crying?” ASx; INFECTION: Fever, sweating, tender points in his body Running nose, coughing, vomiting, discharge from his ear, yellow discoloration, fowel smell urine, GI does he have distension of abdomen Gases Does he draw up his legs & cry Any relation to feeds

BINDE (Partial) N 1st P Planned pregnancy, Reg F/u Was it term P Any illness Smoke/Drugs, Term, Complicated, Needed special attention, separation, any congenital abnormality Environment: financial how do you support yourself, any financial stress, with whom do you live, repeated visits to ER, anyone in home have psychiatric problems/drugs/alcohol, relationship with your partner PMHx – diseases, hospitalizations

Rita Gordon, mother of 5w who vomit for the last 10d



Pyeloric stenosis GERD Infection Alleric to milk overfeeding Not Pyloric stenosis If the colour of vomit is yellow or greenish discolouration Not projectile + Wt loss

GERD No wt loss at 6 weeks Wt loss at 18 mo due to anaemia,due to bleeding due to oesophageal bleeding

Confidential – give it early according to the cues. Depressed: after my son become vomit or preceding the vomit. Not reliable history.

CC OC fD O: C; Off & on/All the time How many/day Increasing/Decreasing or same? COCA±B Forceful Feed: Formula/Breast? COCA How much F do you give? & How much does he vomi t out? AA: Any particular posn improves it? ( GERd upright better) IMPACT: WT & Dehydration Do you feel he is still hungry after you feed him? How many diapers do you change,Now & at the beginning? ASx: wt & s/o dehydration Gerd – no weight loss Pyeloric stenosis – yellowish colour (ask specifically about the colour, relation to feeding – up to half hour can be related to PS, what about position, do you burp him?) ASx: Infection – any signs of infection BINDE: N 1st If formula fed? Did you change the Formula? Have you considered breastfeeding? Is there any reason not to breast feeding? Overfeeding – overweight Allergy – less likely if she uses it from birth Abdominal distended B PWas it planned pregnancy Were there regular F/u? How do yu feel about being a mum? MOOD & INTERSET Any chance of being depressed? Any chance you feel like harming the baby or yourself? Do you have any support at home? “I see you are preoccupied / overwhelmed” Child abuse/neglect If there is a growth chart – it it is from the beginning. 4 min on the child, last 1 min to concentrate to the mother.

Sandra Bullock, 19 y.o, 8m child, pale



Intro Name of the child CC: Anemia ? OCD IMPACT Causes: Red Flags (bleeding & BINDE) Past MH FH ENv: Old house Pale – what do you mean? Who told you that OCD

If told by another person/ If you think about it,any chance he was pale before that or just now?,& you were unaware I like to see how it has affected your son: IMPACT: Is he as active as before? Crawl? Playful as before? LOC? Heavy breathing? Stop to breath when you feed him? T: I’m going to ask you some questions that could be the cause of this? Asx: Infection: Sweat, Fever, Loose of weight, Painful points? Does your child have bleeding? Bruises? Coughing blood? Tarry stool? BINDE: N 1st What do you feed him? (B/F) Any solids /supplements P: Was it a term Preganacy? IMMUNIZATION: ENV: With whom do you live? Any financial concerns? Old/new home Do you’ve a supportive family? PMH: FH: Any bleeding disorder? Repeated lver disease Any gall bladder disease or splenectomy Certain blood disease are more common in particular parts of the world & for that reason I need to know your & partner’s ethnic background.

ANEMIA: 29/F MCV Inc (Counsel)



D/d:[TN10/H21] A. MEGALABLOBALSTIC: a)B12 defeciency: I. Diet (vegan) II. Gastric: a)Mucosal atrophy b)Pernicious An c)Post G-ectomy III. Intestinal Absorption a)Malabsorption (Crohn’s,celiac sprue,pancreatic disease) b)Stagnant bowel (blind loop,stricture) c)Fish tapeworm d)Resection of ileum b)Folate deficiency I.Diet II.Intestinal malabsorption III. Drugs/Chemicals: a)Alcohol b)Anticonvulsants c)Methorexate d)Birth control pills IV. Inc demands: V. Pregnancy/Hemolysis/Hemodialysis/Psoriasis c)Drugs (Methroxate,azathioprine) B.Non Megalobalstic: I.Liver disease II.Alcohol III.Hypothyroid IV.Myelodysplastic syndromes Start By saying: I’ve the results of your test with me & before I proceed I need to get some information abt you that will help me understand: If Pt asks if Serious: STOP & ask WHAT is her concern. There can be many reasons for this result,though most are simple,however some can be serious, 2QNS: 1.What is the reason for doing the test 2.Is it the first time? Then explain the results

•Search for the cause of iron deficiency, including very careful consideration of occult gastrointestinal bleeding •Menorrhagia must be convincing before it is accepted as the sole cause of iron deficiency. This may be an opportunity for early recognition of a gastrointestinal malignancy—don’t miss it! •A reticulocyte response should be evident within one week of beginning iron therapy, with subsequent improvement in the Hgb of about 10 g/L every 7–10 days. •If the Hgb fails to respond as anticipated, consider that there may be: oongoing blood loss ouse of other medications that impair iron absorption oa different or concurrent cause of anemia and/or an impaired erythropoietic response o compliance issues •Gastrointestinal side effects are the most common reasons for non-compliance: ouse a graduated approach to dosing. Begin with a single tablet taken after a meal. On a weekly basis, as tolerance permits, add another tablet until the patient is taking one dose with each meal. Thereafter, gradually shift the timing of the doses to the beginning of meals osmall oral doses may be adequate in patients that are susceptible to gastrointestinal upset. In the elderly, daily doses of elemental iron as low as 15 to 50 mg are effective in the treatment of iron deficiency anemia9 In pregnant women, 20 mg/day of elemental iron, started at 20 weeks' gestation, is sufficient to prevent iron deficiency11 oiron contained in enteric-coated tablets is poorly absorbed. These products should be avoided •Some physicians replenish iron stores while others prefer to stop therapy when the Hgb normalizes, so that further blood loss will not be masked by robust iron stores. As a compromise: ocompletely replenish iron stores when the cause of iron deficiency has been identified and corrected odo not replenish iron stores when investigation has failed to

Therapeutic Tips •Search for the cause of iron deficiency, including very careful consideration of occult gastrointestinal bleeding •Menorrhagia must be convincing before it is accepted as the sole cause of iron deficiency. This may be an opportunity for early recognition of a gastrointestinal malignancy—don’t miss it! •A reticulocyte response should be evident within one week of beginning iron therapy, with subsequent improvement in the Hgb of about 10 g/L every 7–10 days. •If the Hgb fails to respond as anticipated, consider that there may be: oongoing blood loss ouse of other medications that impair iron absorption oa different or concurrent cause of anemia and/or an impaired erythropoietic response o compliance issues •Gastrointestinal side effects are the most common reasons for non-compliance: ouse a graduated approach to dosing. Begin with a single tablet taken after a meal. On a weekly basis, as tolerance permits, add another tablet until the patient is taking one dose with each meal. Thereafter, gradually shift the timing of the doses to the beginning of meals osmall oral doses may be adequate in patients that are susceptible to gastrointestinal upset. In the elderly, daily doses of elemental iron as low as 15 to 50 mg are effective in the treatment of iron deficiency anemia9 In pregnant women, 20 mg/day of elemental iron, started at 20 weeks' gestation, is sufficient to prevent iron deficiency11 oiron contained in enteric-coated tablets is poorly absorbed. These products should be avoided •Some physicians replenish iron stores while others prefer to stop therapy when the Hgb normalizes, so that further blood loss will not be masked by robust iron stores. As a compromise: ocompletely replenish iron stores when the cause of iron deficiency has been identified and corrected odo not replenish iron stores when investigation has failed to

32 M Fever & Tiredness x 6 wks ---- 10 mins focused History

3 Scenarios: H/O Splenectomy IV drug user Unprotected Intercourse

After introduction,Analyse Fever Constitunat Sx Then go to causes from Head to toe End with Liver Risk Fcts Travel Drugs PAST MH FH Social H (Which is linked to Risk Fcts)

Can you tell me more about your fever from the moment it started? O; Sudden/Gradual When it first started did you have any other illness? Did you seek medical attention then? What made you come in today? C; 1.Is it on & Off/All the time/everyday 2.Does it inc/Dec or is it the same? 3.Any variation during the day, like more in morning? Any particular patern? 3rd or 4th day or alt days 4.Did you measure it? 5.How often do you measure it? 6.Which was the highest temp? 7.Does it increase at night? 8.Did you take any meds?/were they helpful? 9.Is it the first time or have you ever had it before? 10.Anything increases or decreases it?

CONSTITIONAL Sx: Fever/chills/N Sweats/wt loss/Lumps/bumps

TRANSITION: I’ve to ask a couple of more qns to help me come to a diagnosis. If you’ve concerns at any time please tell me & I will answer them CNS: HA/N/Vx/Photophobia/neck pain/Neck stiffness Ear pain/Discharge from ear/runny nose/Facial pain/Sinusitis/Sore th/Difficulty swallowing Dental pain/Tooth ache CVS: H racing/Chest pain/SOB RS: Cough/Phglem/wheezing/H-maemesis Contact with TB/Have you ben screened for TB? GI Abd Pain/Diarrhoea/Malena GU Flank pain/burning urine/bld in urine/Inc freq in passing urine MSK Jt pain/Swelling/Skin rash/Ulcers in mouth/red eyes Have you ever been Dsed as a condt called Autoimmune Disease? Or has anyone else in your family been diagnosed? LIVER DISEASE: •Have you ben screened for liver disease? •Have you been vaccinated against Hepatitis A & B? •Sx of Ac Liver Disease: Yellow discoloration of skin & nails/Pale stools/Dark urine/Itchy skin •Sx of Ch L Disease: Inc abd girth/bruises /leg swelling/vomiting bld/memory changes

TRANSITION: I’ve to ask you some questions to see if you were exposed to liver disease without being aware of ,some of these qns may be personal, but it is imp that I ask them.All that you tell me is confidential & the information will not be released without your permission, unless I’m requested by law TRAVEL & CAMPING H Travel outside Canada H/o eating raw fish,raw shell fish.Have you visited a new restrauant? H/O Surgery/Hospitalizations Donated/recvd bld Tattooing/Piercings Smoke/Drink Alcohol/Recreational drugs? Any injectable drugs?

SOCIAL H: Whom do you live with? How long have you been with your partner? If for a specified time with a partner,ask if had any other sexual partners,though this qn is personal,I’ve to ask it as it is imp: When was the last time you’d sex with another partner/ Did you use a condom then? If YES: Ask Discharge/Lumps in groin/Genital ulcers How is wife:Does she have: Fever/Sx/Discharge? RISK FCTS: How do you support your self financially? Have you ben exposed to body fluids/TB H/Ca Any contacts with fever?

HIV SEXUAL HISTORY: Before marriage or before current relationship; 1.Did you have sexual partners? 2.At what age were you sexually active? 3.From that time till now, how many partners did you have? 4.Did you practise Safe Sex (Use of condoms?) 5. What is your sexual preference? M? F? Or Both? 6.What type of sexual activities do you prefer? Anal/vaginal/oral 7.Were you ever screened or diagnosed for STIs? 8.Did you have any sexual relationship besides your regular partner

Laboratory investigations: oHIV antibody test (repeat to rule out lab error) oplasma HIV RNA level (viral load) with the CD4 lymphocyte count is the best prognostic marker for progression to AIDS and survival. oviral drug resistance mutations become harder to detect over time. Therefore conduct a resistance test at entry into treatment program even if use of antiretroviral treatment is not currently contemplated2 oCD4 lymphocyte count and percentage is useful in determining where a patient lies in the continuum of HIV disease and the need for specific intervention (Table 1). Knowledge of the CD4 count can also help to narrow the differential diagnosis in a symptomatic HIV-infected patient. In adults, a CD4 count of 430 to 1360 cells/μL (0.43 to 1.36 Giga/Litre or G/L) is considered normal in most laboratories oscreen all patients for the presence of the HLA-B*5701 allele before starting or restarting abacavir.2 , 3 A positive result indicates a very high risk for severe allergy to abacavir and should be filed in the patient's chart operform a tropism assay to determine the chemokine receptor status (CCR5, CXCR4 or dual-mixed tropic) if considering use of the CCR5 inhibitor maraviroc. A plasma viral load of at least 1000 copies/mL is required to perform this test oCBC, differential and platelet count oliver (AST, ALT, GGT, LDH, CPK, alkaline phosphatase, bilirubin, INR, albumin) and renal (BUN, creatinine, electrolytes, urinalysis) profiles ometabolic profiles (fasting glucose and lipids—total cholesterol, LDL, HDL, triglycerides) ohepatitis B, hepatitis C, syphilis, cytomegalovirus (CMV) and toxoplasmosis serologies ocultures and smears for sexually transmitted diseases as indicated otuberculosis skin tests, sputum cultures and smears for mycobacteria as indicated o chest x-ray

Management of Patients with HIV Infection CD4 Count Action (cells/μL) At all levels • General counselling (safer sex, nutrition, need for follow-up, importance of adherence, etc.) •History and physical examination every 3– 6 mo •Plasma viral load and CD4 count at least every 3– 4 mo •Herpes suppression if frequent recurrences (more than 4–6 episodes per year) •Syphilis serology •Pneumococcal vaccine; hepatitis A and B vaccines if appropriate; update diphtheria, tetanus and inactivated polio vaccines as needed; consider annual influenza vaccinations •TB skin test and isoniazid prophylaxis if indicated (consider CD4 Count Action (cells/μL) repeating skin test yearly) < 500 • Plasma viral load and CD4 count every 3– 4 mo • Clinical evaluations and laboratory investigations at least bimonthly if symptomatic, diagnosed with AIDS, or on antiretroviral therapy < 200 • Start prophylaxis for Pneumocystis jirovecii pneumonia (PCP) < 100 • Start toxoplasmosis prophylaxis if seropositive and not on trimethoprim/sulfamethoxazole for PCP prophylaxis < 75 • Consider MAC prophylaxis < 50 • Screen by an ophthalmologist for early CMV retinitis (repeat at 3– 6 mo intervals) or consider CMV prophylaxis

Advise patients with HIV infection and immunosuppression that their risk of infections can be reduced by following good hygienic practices. 1.Ensure thorough hand washing after contact with potentially contaminated substances (diapers, soil, uncooked meat and produce) or handling pets 2.Avoid raw or uncooked meat and eggs, e.g., Caesar salad 3.Drink from treated water sources only 4.Avoid handling sick animals or pet (especially cat) litter 5.Avoid cat scratches and do not allow cats to lick wounds 6.Avoid contact with reptiles

45M with tiredness x 6 weeks



As I understand you’re having Tiredness since 6 weeks, can you tell me more about it since it all started? Pt says he is concerned. STOP & ask about his concern. Pt says, he is also never been so tired before. Clarify: What do you mean about Tiredness? •Sometimes I do not feel refreshed after sleep. •Do you feel lack of energy? Like you cannot move your arm above your head.

The Statement: NOT REFRESHED ANYMORE points to an organic cause OCD + Relation to sleep +/- Mood If Mood Sx + ------ MOAPS If Organic cause ---- Red Flags OCD At onset you can ask if there were any flu-like Sx initially (Thyroiditis) •Do you sleep more •When do you go to bed? •Do you wake up in the middle of the night •Which time of day/Night do you feel most? •Ask Nature of work; If shift •With whom do you sleep? •Does your partner C/o you snoring or jerky movts of limbs? (Restless Leg) •Do you feel better in morning or evening(if tired in morning-->Depression If evening-------->Organic cause) •Depression 1st Low mood then tired •In organic 1st Tired the Low mood

11.Ask Constitutional Sx first: Fever/Wt loss/Night sweats/Chills/Lumps & Bumps Then quick review of Sx: 12.Cardiac: Chest Pain/SOB/Palpitations 13.Pulmonary: Cough/Wheezing/Phglem 14.GI: N/V Abnormal bowel movts/Diarrhoea/Malena/ 15.Liver: Dark urine/Yellow sclera/Abd pain/Loss of aooetite/Pale stool/Itchy skin 16.GU: Change in color of urine/Amt of urine/Cloudy/Frothy urine/Dysuria/Facial swelling 17.Anemia: Bleeding gums/Easy bruising/Malena/Haematuria/Female: Meorrhagia & LMP 18.Autoimmune Disease: Joint Pains/Skin rashes/Oral Ulcers 19.Endocrine: Thyroid: Feel hot/Cold Skin Moist/Dry/Tremors/Wt loss If Pt has thyroid Sx,ak if on Thyroxine When Dsed If thyroxine levels are monitored? 20.DM: Risk fcts: FH & Lifestyle Once Pt has DM in history, GO over ALL Sx & Sy:

RISK FCTS: 7.Diet 8.Exercise 9.FH 10.Smoking 11.Alcohol 12.Recreational drugs

PAST MEDICAL HISTORY: Any medications/OTC/Herbal/LMP Surgery/Hospitalization FAMILY HISTORY: DM/HTN/Stroke/MI

SOCIAL H: Habits With whom do you live? How do you support yourself financially?

Hypothyroidism (underactive thyroid) is a condition in which your thyroid gland doesn't produce enough of certain important hormones. Hypothyroidism upsets the normal balance of chemical reactions in your body. It seldom causes symptoms in the early stages, but, over time, untreated hypothyroidism can cause a number of health problems, such as obesity, joint pain, infertility and heart disease. The good news is that accurate thyroid function tests are available to diagnose hypothyroidism, and treatment of hypothyroidism with synthetic thyroid hormone is usually simple, safe and effective once the proper dosage is established. Back to Content NEEDLE STICK INJURY Michael Jackson, Nurse in hospital, Needle stick 20min ago; History and counsel, 10min Variations: Janitor who was pricked in junk yard (here touch TT prophylaxis) 0.3% - HIV; 3% HCV; 30% HBV “The treatment will be the same no matter what is the situation of the other patient...” Did anybody talk to him? Did he accept to get his HIV status? “By law we are not allowed to take his blood without his consent”

QUESTIONS RELATED TO EVENT:

1.Size of needle 2.Blunt/hollow 3.Any blood on it 4.How deep was the injury? 5.What was gauge of needle? 6.Where was the location of the prick? 7.Any bleeding after that? 8.Whether he was wearing gloves? 9.What measures did he take? (Wash hands?) 10.Is it the first time? If Pt insists on doing HIV testing of the contaminated pt: I know it is of great concern about the pt’s HIV status, however from the ethical point of view we cannot do the HIV test without the pt’s consent. I can go after our interview & personally request him If Still he insists or ask for CD4 count: How do you think this will help us? It is a reasonable way of thinking. There are different conditions reflecting CD4 count & ethically not the right step We do it to obtain Pt’s information & not for the best interest of the pt However whatever the CD4 count it makes no sense in our management. We’ve to follow protocol: RISKS Give him the risks of being infected with N Stick injury: HIV------->0.3% Hepa C----->3% Hepa B-------> 30% .” In order to know what is the best line for you I need to ask you more questions. Do you know what the chances for getting infected are? (Out of 1000 people – only 3 will be affected). ASSESMENT: Being a health care provider – 1.Have you been vaccinated before for Hepa A & B 1.1How many doses? 1.2When was the last dose? 2.Liver Disease: Have you ever been yellowish? Itchiness? Dark urine? Pale stool? Btuises in body? C Sx: Repeated infections? Chronic diarrhea? Have you been screen for HIV or HCV? I am going to ask you some questions if you were exposed before for any of the viruses mentioned above 1.Any travel outside Canada? 2.Any surgery 3.Any blood transfusions/ 4.Tattoos/Piercings SH With whom do you do live. For how long have you been together

COUNSELLING:

Whenever we face such a situation,we’re faced with three possible infections that could be transmitted: HIV------->0.3% Hepa C----->3% Hepa B-------> 30% Good news – HBV high risk but good plan; we are going to measure the titer of antibody in your blood. If Okay,you need not worry,if low you may need an Immunoglobulin or revaccination What do you know about HIV. If infected,some bcome carriers,not all develoe into AIDS,we will screen you today: For screening you we need to sample today to have base line. Most of the patients don’t react until 6wk, few until 6m – we have to take it in these times. If at the end of 6 mo tests come back negative, you’re cleared If not you’re infected Other options: we will also refer you to occupation clinic – Who will start you on prophylaxis treatment. It consists of three medications usually. They will explain to you which medication and describe the SE. It will decrease the chances by ...% HCV – This is of concern as We don’t have prophylaxis yet there is more than 50% to be carrier, more than 50% of them become chronic, 50% of them will get cancer. However certain medications might help like Interferon & Anti retrivirals

“How do you feel about it?” Sometimes patients are overwhelmed and might harm yourself or others” From now till the results of your blood tests: Practise Safe sex Do not donate blood Joint a support group.” I wii file an incident report.”

35y.o, male, counselling about HIV test Wants to do HIV test as his partner has tested =ve



As I understand you’e here as you want a blood test.Can you tell me which blood test you specifically need? Can you tell me what made you come in today? **PT: I feel I’m at risk screen me for disease We cannot order all bl works, we’ve to look for a specific disease e.g: for TB we do a CXR/DM BSL/HIV Bl tests ** My Partner has tested for HIV + EMPATHY: I’m sorry, when was that? How is she doing now? How long have you two been together? How has it affected you? How do you feel? This can be a difficult for you, & you’ve done the right thing,& definitely we can arrange for a blood test “20 years ago we had no options, now even if you are positive we will have treatments and prophylaxis.” In order to get the diagnosis we need to do more questions.” 1.“Have you ever been screened for HIV”or HCV If Yes: When & where? 2.Any Sx OF HIV CSx, Mouth, Ulcers,difficulty swallowing RS;Cough ,Diarrhea, Discharge,Ulcers,Skin rash/yellowish, Dark urine/Pale stool I am going to ask you some questions if you were EXPOSED BEFORE for any of the viruses mentioned above 1.Any travel outside Canada? 2.Any surgery 3.Any blood transfusions/ Tattoos/Piercings? SEXUAL HISTORY Relationships now and before / Sexual predilection / Sexual practice When were you sexually active? How many partners have you had? Did you practise safe sex? PMH Any long term disease/hospitalization/allergies/medications

COUNSELLING “What do you know about HIV?” “Nowadays we have better control over the disease. Once they start get the infection they called AIDS patients.” “HIV is a virus which affects our immunologic system. It is different if you are the carrier as oppose to have symptoms when you are an AIDS patient. HIV is a virus. HIV attacks the immune system itself - the very thing that would normally get rid of a virus It takes around ten years on average for someone with HIV to develop AIDS ” Is that reasonable? Am I clear? Do you have any questions? In order to know whether you are infected or no we need to do a blood work. We need your consent for that. They will give you the results within two weeks. If the results are positive – they will call you back. If it negative – they will not call you. Options to send the sample: Nominal – with your name Non-nominal – put a bar-code (the public health and the doctor will know the identity) Anonymous – put a barcode on the sample and only you know the results (needs a lot of counselling. “How do you feel about it?” Sometimes patients are overwhelmed and might harm yourself or others” From now till the results of your blood tests: Practise Safe sex Do not donate blood Joint a support group.” I like you to know that in 2011 there are a lot of options open, with Rx it is controllable & people can live with it for a long time. If you test positive you’ve a have legal obligation to inform your partner.

37y.o, Male, HIV results came back and are positive



Divide time: 2min telling the results, 3min assessing symptoms, 2min explain about the virus, 3min the plan HIV treatment in Ontario is covered. “Nice to meet you. Or Hello” Because this is the first time I see you I am going to ask you some questions, to get a better understanding of your results: “Why/Who/Is the first time/When you did it?” ** Somebody I knew died from it last week “Who is the person that you got it from him?” (nature of the relationship) “People don’t get it from normal daily contact. Was there any direct contact?” SPIKE Setting

Perception – what do you know about HIV? ―What did you think was going on with you when you felt the lump?‖ ―What have you been told about all this so far?‖ “Are you worried that this might be something serious?” Invitation – how much details you want me to discuss? DO you want someone else to be present? ―Are you the kind of person who prefers to know all the details about what is going on?‖ ―How much information would you like me to give you about your diagnosis and treatment?‖ “Would you like me to give you details of what is going on or would you prefer that I just tell you about treatments I am proposing?” Knowledge ―Unfortunately, I’ve got some bad news to tell you, Mr. Andrews.‖ “Mrs. Smith, I’m so sorry to have to tell you….” Empathy – “What are your expectations from this visit?” If he is not very anxious you might take some time until giving him the results. Otherwise you give them immediately. “I wish I’d better news for you. Unfortunately the results came back and I am very sorry to tell you that the result is positive.” Silence. Wait x 10 sec if he cries “How do you feel right now?” Do you need more time/ Do you need water? Do you want me to proceed? **If mistake? “Whenever we do a screening test we confirm it if it positive. So the result is very accurate.” The initial test is ELISA & then we do a confirmatory test called Western Blot Part of F/u atre other tests like the CD4 count & Viral load

SOCIAL Hx: We will ask you several questions concerning your sexual partners. Drug use Asx: CSx: AIDS Sx: PMH: any long term disease? HTN/DM? Any hospitalizations/Surgeries? If does not want to inform his wife From experience it is not necessarily that your partner will leave you. From that reason we need to inform your wife. Part of the public health job is to tell her. The same measures we are taking for you we should do for her. It is better that she will know it from you rather than from the Public Health – otherwise she’ll loose the trust in you. Do you have any symptoms relating to HIV? PMHx and drugs. COUNSELLING If asked what he knows about HIV – don’g repeat. Otherwise you explain here. From HIV+ to AIDS. Significance of CD4 and Viral load: Viral load,amt of HIV virus existing in your body, lower the viral load,& higher the CD4 count, better condition We should think about HIV these days like a chronic disease as DM or HTn,it can be controlled but not cured. Part of your treatment is to refer you to HIV clinic – they will treat you based on these parameters. The newer medications are effective and control your disease – however they have side effects. How’s your mood, how you feel about that, there are a lot of support groups. I’ll give you “hot lines” number. From now on you have to practice safe sex & do not donate blood

In case of the resident who was asked to backup his supervisor orthopaed 1.I am competent – to emphasize 2.Short term – we don’t have time so we need to see her urgently 3.Long term – solve the situations that it wouldn’t occur again Dr. Smith, Chief of staff of the hospital, ask another doctor to talk with the doctors me because they smell alcohol from the doctor. You smelled like alcohol. People have different ways to relieve their stress – how do you relieve your stress? Team worker – interpersonal relation It is better to provide prescription than getting pregnancy “I may share your point of view – that doesn’t say it gives me the right to impose my beliefs.” My concern is if we face the same situation in the future...what will we do? Why won’t we contact the College? Don’t give any names. In case of report – it should be reported to the college. “We are here to help you. Moving to new place can be stressful. The reason of this meeting we have received two complaints – they claimed they have smelled alcohol from you. Is that happened? If you don’t mind me asking few more questions: do you drink more, or you did it on lunch time? Before working here – where else did you work? Did you ever have a complain about drinking? I would recommend that you will contact the program for doctors who drink. They will suspend your license. After stop drinking you will resume your work. At the end you will have your career back.

24M: HA 6 wks ER 10 mins H & Counsel



OCD PQRSTUV INC ICP: •SOL: Brain Tumors •Mets •Infection •Toxoplasmosis HA + Inc ICP Constitutional Symptoms: fever: Always ask what came first: fever or headache * If primary tumor; FH of Malignancy H/o Cancer,Leukemia,Melanoma H/o HIV: •Ask if HIV status known, • Have you ever been checked? •I’m concerned because of the risk factors involved IF HIV status known ask: •When was the last time you saw your Dr • What was the last CD4 count • Are U on any Anti AIDS meds? •TB Skin test results •Syphillis tst results •Date & results of PAP’s smear

*Ocurence f opportunistic infections,malignancies, *STIs: Hepatitis B & C,Syphillis,Gonorrhoea,Chlamydia,Molluscum contagious *Other bacterial infections,fungal infections,Malignancies * Travel History,illness while away & use of preventative vaccines * Medication History: *Antiretroviral History (including response,CD4,Viral load) adherence,toxicity,any resistance testing & results If HIV or AIDS & not on meds: Asses condt by asking: Constitutional symptoms: •Fever •Repeated chest infections •Cough thrush •Odonophagia •TB •In Female: Cx al Ca

OCD ONSET: COURSE: When Pt says HA now Ct ous Ask: •When did it become constant? •In beginning how often did you have it? •What time of the day? •Is it more in the morning? Or is it worse in the evening? •Does it wake you up? DURATION: PQRST UV S: How was it in the beginning as compared to ‘Now’ U Qns for empathy** • How has it affected U in your daily life? • How r U coping with it? • How do U feel abt it? • What r your expectations from today’s visit? Aggravating fcts: Coughing/leaning forwards/lying down Alleviating fcts:

ASOC Sx: CONstitonal Sx: Fever/nightsweats/chills (if before headache indicates patho) Ask when Wt loss started LOCal Sx: NEURO Screening: 1.Vision changes: What type of problem? 2.Hearing abnormalities 3.Difficulty swallowing 4.Weakness/Numbness 5.Difficulty finding words 6.Difficulty in balance or repeated falls 7.Changes n bowel/Urine Loss of bladder control 8.LOC 9.H/o Seizure MOOD Changes MEMORY problem Changes in CONCENTRATION Has anyone told you that you’ve been acting strangely? H/O INJURY: To head Did you have a fall & hurt your head?

EXTRACRANIAL: EYE: Did you notice any redness or need eyeglasses? Sinusitis: Facial pain/flu Throath pain Dental pain PMH: RISK FCTS: Do you smoke Take EtOh Take recreational drugs? Route Tattoo

COUNSELLING: Do you have any qns for me? Based on what you’ve told me,the symptoms are concerning & I need to admit you today, as you’d stopped your meds, you may be exposed to an infection Your HA may be caused by this infection. I will refer you to an Infectious Disease Specialist Also do some blood investigations & Imaging of your head. DIAGNOSIS: CNS Toxoplasmosis in HIV +ve Male

22F sudden loss of vision x 2 wks seen by 2 drs one opthal



As I understand you’re here because you’d loss of vision in (R) eye x 10 days, I understand you’ve been seen by 2 Drs •What did the drs tell you? •What diagnosis did they give you? •Any investigations were done? •How’re you doing today/Tell me how it all began...... OCD

ONSET: Sudden/gradual What were you doing at that time? Anything particular happened at that time? Is the loss all the time or off & On? Ask a little about local Sx: Pain Photophobia/Injury U V SOCIAL H:

•Speak about confidentially here • Who lives with you? •What is your relationship? •Any difficulties in your relationship? Emphasize confidentiality • Was there a stressful situation before you lost your vision? •Let us go back to that day........ •Make sure no suicidal/Homicidal ideation COUNSELLING: This seems like a stressful situation for you & sometimes when we face such situations our brain finds it difficult to deal with it & this stress can be manifested by loss of function. In this case you saw something that made you lose your sight.It is not uncommon & called CONVERSION DISORDER I will refer you to a therapist to help you understand the stressor in your life & learn how to handle it. LOSS OF VISION: 32 M/F Pt presented with vision loss x 2 weeks OCD Onset after car accident Here enquire about the nature of accident Ask whether she or other driver was hurt & how is her driving now, does she still drive? Gradual C: Is it increasing now?/Same/Varies at certain times of day U &V CONSTITUNAT SX: Assoc Sx: *HA: Here +ve,OCD: PQRST: When does it occur? Morning or evening Vomiting +/Quality---- projectile Weakness/Numbness/Difficulty finding words ENDOCRINE: Thyroid Disease: feel hot/cold/Warm & moist skin/tremors Pituitary:Sometimes Pts in similar situations can notice breast engorgement & secretions from breast (For Males) & changes in sexual life ,desire & habits In Females ask directly about amenorrhoea galactorrhea SX of Acromegaly: Inc size of shoes/Tight ring FH of Kidney stone/Pancreatic Ca/Diarrhea/Foul smelly stools

Past H Fh Social H VISION LOSS 1.40 M difficulty in vision 2 wks 10 mins H & C 2.22F sudden loss of vision x 2 wks seen by 2 drs one opthal (Somatization GAO -207) 3.40M diificulty in vision x 4 wks seen by optometrist counsel All D/vision: Screening Qn: What do you mean? Pt will answer: I’m not seeing well Now ask close ended qns: 1.One/(B) eyes 2.Blurry V 3.Double vision: a.Relieved by covering one eye? b.Horizontal/Vertical/Oblique c.Worse in one direction of gaze? d.Fluctating or constant? (Gets worse at end of day) 4.Loss of vision 5.Curtain falling 6.Dark spots/flashes 7.Difficulty seeing on sides/when you drive do you have difficulty changing lanes? 8.Do you bump into objects when walking? 9.Do you see halo around objects? OCD: O;Suden/gradual Painless/Painful PAIN: Assoc with: • Blinking •Eye movts •HA/N/V •Brow/Temporal pain •Photophobia •Gritty sensation How has it affected your life Has it happened before? Asso Sx: Fatigue wt loss,joint SxNight sweats,ever Polyuria/poly dipsia Tingling /Numbness Past Occular H: Use of eyeglasses/Contacts: Duration H/O Occular surgery,Laser Rx,Infection,trauma,FB Presence of Ch eye disease: Glaucoma/DM PMH: Htn/DMMS/HIV Asthma Allergies Meds:Occular meds Current+Past

Somatization Disorder

22 YOF Somatization disorder 4-2-1-1 If seen by a surgeon – suspect somatisation. What did the surgeon tell you. OCD PQRST During the day or night. CSx

Jaundice, white stool and dark urine Foul smell, bulking, droplets Change in bowel movement First time to have this pain or had it before (V) MRI – why do you think it is important? Somatic pain disorder / Somatization Pains: headache, joints, back, pain with intercourse Sexual: You are here because you are concern. The pain you have, and multiple doctors – all these are consistent with somatisation. Once every 2-3weeks See Zu09: 207-8 Introduction to OBGYN OCD COCA +/- Blood ΑA ASx:– which organism MSGO PMHx OBGYN MAP CC Menses Gynecology history Obstetriscs h Sexual h VAGINAL DISCHARGE. OCD COCA ΑA AsSx – which organism MSGO PMHx

AMENORRHEA OCD MAGOS VAGINAL BLEEDING OCD COCA +/- Dc ΑA M ASx G O SHx PHx FHx

INFERTILITY I+O Tr Partner C M G S Intro How many months trying to conceive? If less than 35 y – wait for 1yr If around 40 – wait for 6m If greater than 40 – immediately O – if children from previous relationship Transition: ―In order for a couple to achieve pregnancy both partner involves should be relatively healthy and capable of having children. For that reason I need to ask questions about your and your partner’s health. Some of these questions can be personal, but important to ask, but I can assure that everything king is strictly confidential. The male factor is responsible for 40%.‖ COITAL H. How often do you have intercourse? Do you monitor tmp? MGOS All causes of secondary amenorrhea: Endometriosis Past medical history Family History Social history

MENSES Use the word ―period‖ 1.When was your last period? 2.Are your periods regular / not 3. How often? 4.How many days? 5.How many pads do you use/change? 6.Are the pads full? 7.How long does it last? 8.Are they heavy? 9.Do you see clots? 10.Between periods do you have spotting? 11.From your last menstrual period was your period different from the current one? 12.At what age did you start your periods? 13.Were they regular/irregular? 14.When did it become regular? 15.Are your periods painful / painless? 16.If irregular, from beginning? 17.Discharge – ask if pregnant and when LMP

GYENECOLOGY 1. Any history of Gyn. Disease – polyps or cysts 2. History of pelvic surgery (if yes – when?) 3.Have you used any birth control? When/type/any complications? 4.If less than 50 – have you ever done PAP (if yes – when and what were the results?) 5.If 50 and older – in addition ask for mammogram 6.If more than 65 – ask for bone density OBSTETRICS Have you ever been pregnant How many times, how about abortion and termination/ Abortion – termination medically; How many live children, what was the route, any complication? Were there any complications with the children? During pregnancy: any HTM/GDM/Vaginal bleeding How do you feel about (miscarriage?) If NULLIPAROUS:FH of HTN/DM?cong anomalies/repeatd C S/Twins

SEXUAL Hx: 1.With whom do you live? 2.How long have you been together? (a relationship below 6 month is not stable) 3.If you live alone – are you in relationship? 4.Are you sexually active? 5.Do you practice safe sex – using condoms? 6.When did you start to be sexually active? 7.How many partners you had last years? 8.What is your sexual preference? 9.What type of sexual activity do you practice? 10. Have you ever been diagnosed with PID 11.Any Vaginal discharge? 12.How about your partner? Does he have any symptoms have you ever been screned for HIV? PREGNANT IN T3: Reg F/U: No-----> Social Hx Yes:------->When If recent ask 2-3 qns about PET: 1.What was your BP 2.Was there swelling? MUM’s STABILITY: 1.Abd pains 2.Abd cramps 3.Vaginal bleeding or discharge 4.Any gush of water BABY: 1.Is baby kicking like before? 2.10 movts/12 hrs

19 year old with Vaginal discharge for the last 10 days History 5 minutes



VAGINAL DISCHARGE. OCD COCA ΑA AsSx – which organism MSGO PMHx: Recent use of Ab + DM

Intro: How can I help you today? O: Sudden(Allergey)/Gradual How did it start? C: 1.Is it all the time or on and off? 2.Is it increasing, decreasing or the same? COCA + BL 1.Can you estimate the amount for me?Do you use pads? How many? 2.How about the colour? Is it greenish, whitish or yellowish? 3.How about the consistency? Is it thick or watery? 4.Is the smell offensive? 5.Is this your first time? A & A:Does it increase after IC? I would like to ask you a few personal questions, hope you don’t mind? Sexual Hx: as part of A & A 1.Are you sexually active? 2.Any relation to your periods or with intercourse? 3.Do you have any pain with intercourse? 4.Any itching, redness, blisters or ulcers? U: V: Associated symptoms: LOCAL Sx: Pain with IC Itching/redness/blisters/warts/ulcers GU: Any burning in urination in urination? GI: Any change in bowel movements? PID : Any abdominal pain? If yes, then OCD, PQRST. :MSK: Any ulcers in mouth, difficulty swallowing, joint pain, skin rash or red eyes?

Constitutional Sx:

Menstrual Hx: 1.When was your last menstrual period? 2.Are your periods regular? 3.Was the last period the same as before? Gynecological Hx: 1.Do you use any form of contraception? 2.Have you had a pap smear? When and what was the result? Obsteterics Hx: 1.Have you ever been pregnant? 2.Have you ever had an abortion or miscarriage? Sexual Hx: As I understand you’re in a relationship… How long? Do you practise safe sex? Does the partner have any urinary symptoms,discharge? Before this? What age were you sexually active? How many partners in last one year? PMH:Since it is 1st time I’m seeing you,I need to ask some qns about PMH: SHx:

RX: Infectious Diseases: Sexually Transmitted Infections

Table 1: Differential Diagnosis of Vaginal Discharge1 , 2 Candidiasis Signs/symptoms: Trichomoniasis Bacterial Vaginosis Pruritus + + – Odour – + + (fishy) Discharge white, clumpy & curdy off-white or yellow, frothy grey or milky, thin, copious Inflammation + Simple tests: + – pH < 4.5 > 4.5 > 4.5 "Whiff" testa – Microscopic findings: +/- + Specific budding yeast, psuedohyphae motile trichomonads clue cells,b predominant Gramnegative curved bacilli and coccobacilli PMNs ++ +++ – Lactobacilli + – – a. Malodour often intensified after addition of 10% potassium hydroxide (KOH). b. Clue cells are vaginal epithelial cells covered with numerous coccobacilli. Back to Content 36 weeks pregnant with vaginal bleeding for 2 hrs History 5 min

Differentials: 1.When did the bleeding start? 2.How long has it been? 3.Were the pads fully soaked? Any clots? 4.What were you doing at the time? 5.Any H/o trauma? 6.Did you have any abdominal pain? If yes: •Did the pain start first or the bleeding? •Are you having any pain now? •OCD, PQRST 7.Any gush of water? 8.Are you under regular F/U? 9.When was the last F/U ? If missed, why? 10.Symptoms of pre-eclampsia: a.Weight gain? b.Headache? c.High blood pressure? d.Flashing lights or disturbance in vision? e.Swelling? 11.Stability of Mother: .........................? Have you had an U/S? When was the last one? # of babies? Position of placenta? Amount of fluid? 12.Stability of fetus: Is your baby kicking like before? Obsteterics Hx: 1.Have you ever been pregnant? 2.Have you ever had an abortion or miscarriage? 3.Any complications during previous pregnancy?

39 year old with vaginal bleeding for 50 days History 5 min OCD + COCA +/- Discharge AA ASx: M G O S Risk Fcts: GPOS D/d: PMH Fh SH

INTRO:

1.What made you come here today? 2.Did you seek medical attention before? OCD: O: How did it start? What were you doing at the time? Did it start gradually or suddenly? C: Is it on and off or all the time? Is it increasing, decreasing or the same? COCA Can you estimate the amount for me? Foul smell? A&A: Is there any relation to periods or with intercourse? Menstrual Hx: 1.When was your last menstrual period? 2.Are your periods regular? 3.Was the last period the same as before? 4.Can you differentiate this bleeding from periods?

I’m going to ask a few qns to see how it has affected your life: IMPACT: Are you having any dizziness? Hrt racing? LOC? Associated symptoms: CSx: Local & Mets 1. Local symptoms: Any itchiness, redness, discharge, pain during intercourse? Itching/rednes/blisters/warts 1. Any abdominal pain? When was your last Pap’s smear? What was result? O Sexual Hx: 1.With whom do you live? 2.Are you sexually active? D/D; Hypothyroidism Bl thinners Bleding disorders PMH FH of Ca

AMENORRHOEA 22 yr old Female



PEP: 1.what is your Ds? 2.What is your inv? 3.What is your Rx?

Always R/o pregnancy Intro: As I understand you’re here today because you did not have your periods since last 6 mo….. Can you tell me more about it? CC-------> When was your LMP? Any spotting in between? Let us talk about your periods from the beginning…….. 1.When did you have your 1st period? 2.Was it regular from the start? Or was it irregular? 3.When did it become irregular? 4.When your periods were regular,How often did they come? 5.How long did each cycle last? 6.When irregular,How often did they come? How many days did they last? 7.When periods were regular, were you using any contraception? If Yes: How long? When did you stop?(if Inj Depo provera I yr post injection amenorrhoea OC can be upto 6 mo Amenorrhoea) With whom do you live? Are you sexually active? Any chance that you may be pregnant? Ask Sx of pregnancy: •Breast tenderness •N/Vx •Increased visits to washroom OB Hx: Any time you were pregnant? Any abortions or miscarriages? RISK FCTS: I’m going to ask you questions to help reach what could be the cause HYPOTHALAMIC: 1.Are you under stress? 2.Are you losing wt? 3.How do you perceive yourself when you look into the mirror? 4.Do you exercise excessively? PITUITARY: 1.Any change in vision/Any difficulty in seeing on sides or changing lanes when driving? 2.Discharge from nipples & breast engorgement? THYROID: 1.Do you feel hot when others around feel cold or do you feel cold when others around feel cold? 2.Do you have constipation/Diarrhoea? OVARIAN: PCO: 1.Any acne 2.Increased facial hair? 3.Are you concerned about your weight? 4.Are you trying to lose weight? 5.Is there h/o DM? (ask for Sx of DM) 6.Any FH of PCOs or infertility? Premature Ov Failure: 1.Hx of Chemotherapy/Radiation to pelvis 2.Hot flushes 3.Night sweats Ovarian tumors: 1.Increased muscle bulk 2.Change in voice C Sx: Gyn Hx: Sexual Hx; Any H/o STis PMH: Since it is 1st time I see you,do you have any H/o HTN,DM Have you ever seen a psychiatrist before or used antipsychotic medications/



31 year old woman with 36 weeks pregnancy:BP155/110 Urine Protein +++



Intro: As I understand…..,you’re here today for a F/u visit,& nurse measured your BP & did a urine test.I’ve your results here & will discuss them with you, But I need to ask you some qns to gain a better insight into your condition 1.Were you ever diagnosed with increased blood pressure prior to this pregnancy? 2.When was your last F/U visit? 3.What was your Bp the last time? 4.What about your blood tests? 5.Were you anemic? Based on your BP & urine, these results are consistent with pregnancy induced HTN,& I need to ask you qns,to see if you’ve Sx pertaining to that. It could be a serious condition 1.Do you’ve H/O: HA ---------> OCD 2.How is your Vision ------------->Do you see flashes of light/Blurring 3.CNS --------> Weakness/numbness 4. Nx/V/Chest pain/SOB 5.ABD PAIN? 6.Bruises on body? 7.Yellow discoloration OF SKIN/ITCHINESS/Pale stool/Dark Urine 8.Swelling feet/Tight shoes/Rings tight 9. Difficulty opening eyes in morning/Inc wt gain 10. Vaginal bleeding/Discharge? • When was the last US: 1.How many babies 2.Is the baby kicking When is the due date? Have you been pregnant before? PMH FH of PET

COUNSELLING: Do you like me to explain it to you? It is a very serious condition What do you know about it? Preeclampsia is a condition of pregnancy marked by high blood pressure and excess protein in your urine after 20 weeks of pregnancy. Preeclampsia often causes only modest increases in blood pressure. Left untreated, however, preeclampsia can lead to serious — even fatal — complications for both you and your baby. Preeclampsia develops only during pregnancy. Risk factors include: 1.History of preeclampsia. A personal or family history of preeclampsia increases your risk of developing the condition. 2.First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy or your first pregnancy with a new partner. 3.Age. The risk of preeclampsia is higher for pregnant women younger than 20 and older than 40. 4.Obesity. The risk of preeclampsia is higher if you're obese. 5.Multiple pregnancy. Preeclampsia is more common in women who are carrying twins, triplets or other multiples. 6.Prolonged interval between pregnancies. This seems to increase the risk of preeclampsia. 7.Gestational diabetes. Women who develop gestational diabetes have a higher risk of developing preeclampsia as the pregnancy progresses. 8.History of certain conditions. Having certain conditions before you become pregnant — such as chronic high blood pressure, migraine headaches, diabetes, kidney disease, rheumatoid arthritis or lupus — increases the risk of preeclampsia. Most women with preeclampsia deliver healthy babies. The more severe your preeclampsia and the earlier it occurs in your pregnancy, however, the greater the risks for you and your baby. Preeclampsia may require induced labor and delivery by Caesarian section. Complications of preeclampsia may include: Lack of blood flow to the placenta. Preeclampsia affects the arteries carrying blood to the placenta. If the placenta doesn't get enough blood, your baby may receive less oxygen and fewer nutrients. This can lead to slow growth, low birth weight, preterm birth and breathing difficulties for your baby. 1.Placental abruption. Preeclampsia increases your risk of placental abruption, in which the placenta separates from the inner wall of your uterus before delivery. Severe abruption can cause heavy bleeding, which can be life-threatening for both you and your baby. 2.HELLP syndrome. HELLP — which stands for hemolysis (the destruction of red blood cells), elevated liver enzymes and low platelet count — syndrome can rapidly become life-threatening for both you and your baby. Symptoms of HELLP syndrome include nausea and vomiting, headache, and upper right abdominal pain. HELLP syndrome is particularly dangerous because it can occur before signs or symptoms of preeclampsia appear. 3.Eclampsia. When preeclampsia isn't controlled, eclampsia — which is essentially preeclampsia plus seizures — can develop. Symptoms of eclampsia include upper right abdominal pain, severe headache, vision problems and change in mental status, such as decreased alertness. Eclampsia can permanently damage your vital organs, including your brain, liver and kidneys. Left untreated, eclampsia can cause coma, brain damage and death for both you and your baby. 4.Cardiovascular disease. Having preeclampsia may increase your risk of future cardiovascular disease. Admit you …….. Stabilize you MgSo4 IV Labetolol May consider Steroids for babe Back to Content



REQ FOR CS



34 wks pregnant primi requesting for CS Intro: As I understand you’re 34 weeks pregnant & arte requesting a Cs. Before I proceed any further,I need to ask qns to reach the best plan. WHY? Pt: I believe it is painfull •What makes you believe it is painful? •Have you’d a prior experience? Pt: My sister had a NVD Never imply that sister did not receive best care There are 2 options: There are a lot of options to control pain nowadays & different people have a different pain threshold

•Are you on regular F/u? •Is it a planned pregnancy? •When was the last time you saw a doctor? if not on reg F/u as she is alone BF left etc always Empathize,Ask how she is coping with him leaving & how she is handling the stress How do you support yourself financially? I can see that this is a very difficult period & I want you to know that there are a lot of help & resources available in the community. I will make sure you’re connected to a social worker who will help you support you & your child & will help you to start your life

If on reg F/U •When was the last time you’d your BP measured? •Sx of PE: Any HA/Nx/V Blurry vision/Abd pain...... MUM’S STABILITY: Abd pain Contractions Vaginal bleeding Vaginal discharge BABY: Is baby kicking like before DUE DATE OBG Hx: Have you been pregnant before? How many times How about abortions/Mc If + •At how many weeks? •What reason •When •Any complications •How did you feel about that? PMH: Risk fcts NEXT come to PAIN CONTROL:

As I understand you want a CS,however if pain is a major concern, there are several options: You can attend antenatal classes that will teach you to breathe, meditate During your delivery a person will accompany you to give you support & emotionally support you If that does not work, there is another very popular method of delivery: EPIDURAL Anaesthesia ... explain.... An epidural block is a common type of anesthesia for labor and delivery. During labor, a needle is placed in the epidural space, which is just outside the spinal canal. A small, hollow tube called a catheter is inserted through this needle. Once the catheter is in place, the needle is removed and medication is injected through the catheter to numb your lower abdomen and birth canal. It may take 10 to 20 minutes to feel pain relief from an epidural block. As labor continues, the medication can be adjusted to help keep you comfortable. Painless & effective SE: rarely it may causeHa/Dizziness/infection & may prolong labour If still does not accept: What is your understanding about CS? It is a major surgery which is effective & lifesaving. However if there is no real indication,NVD is preferred as it is natural With CS there is a scar Longer recovery More bleeding Higher risk of infection Why don’t you think about it Give brochures Refer to Obstetrician for 2nd opinion F/U in 2 weeks

32F with 34 weeks pregnancy in hosp clinic,3yrs ago had an urgent CS due to cord prolapsed,needs her file,counsel her



See if request is logical Ask type of Cs Why not happy with last Cs May be bad experience pain/bleeding/Complications Maybe dead baby Was it 1st Cs or 2nd Was it CLASSICAL Cs? Then always Cs Risk of rupture of Classical Cs ------12% of which 10% will die LSCS risk of rupture is 1%

INTRO: As I understand you’re here cuz you want your file & based on your report you’d a hospital delivery because of cord prolapsed & it was an urgent Cs. Why? PT: Delivery by midwife who wants to look at it We will give you the file, but until then I want to discuss Pt: in a hurry Because you’ve had a previous Cs & you want a midwife. In order to make a proper decision you’ve some imp info to know What happened the last time? When did you know? How many week s were you? How did you feel? What was done? Did they explain it to you? Was there any bleeding/Infection How was the recovery period/ How is the baby/ Is it a boy/Girl How old? Is the baby healthy? If baby was fine & no complications: Looks like it was a right decision & the outcome was good What is your understanding about cord prolapsed? Cord is squeezed between head of baby & pelvic bones.It is a life threatening condition & needs urgent intervention

Have you ever been pregnant other times? How are you doing in this pregnancy? What was your last F/u Bp? US Baby kicking PMH Due Date

Waht is your understanding of Cs? There are different methods: Classical Section Vertical incision Lowere Segment C Section ----->transverse incision Most common is the transverse sectionThe cut is parallel to the fibres & thus it is a strong scar If you go into labour there is a lot of pressure & tension on the scar & with continuous pressure there can be rupture of scar this is concerning There will be a lot of bleeding we might not be able to help you & the mechanism of delivery will stop Chances of rupture in cl S is 12% of which 105 will die However if you want to continue the decision is yours Your life & the baby’s are endangered With a transverse Cs We can give you chance of normal delivery in hospital,as in case we need to do an urgent Cs we can If Not ConVinced: Why don’t you go back to your midwife & talk to her & mention She is trained & qualified We share the same guidelines We can arrange 2nd opinion F/U



54 year old female comes to clinic concerning about using HRT



When a patient has concern about any subject, address it very soon. Don't wait to the end. Dr: As far as I understand you're here as you have concern about using HRT. Patient: yes Dr. I feel I am confused about using HRT. Always ask what do you mean by HRT. So the patient will tell you how much they known about HRT. Dr: I'm glad you're here so we can discuss about it and address your concerns and hopefully by the end of the session you can make a decision regarding using HRT. Or hopefully by doing this discussion you will have a better understanding of HRT. Or you can say: I agree with you as there are a lot of confusion about HRT and the reason for this confusion is that in the past because it was used to be given routinely to all women who reach a certain age, however 10 years ago there was study called " women health initiative" in which the authors found that the numbers of the patients with serious side effects are very high. However those ladies used HRT for a long time. Serious side effects are Cancer, Heart attacks and Strokes. For that reason the routine use of HRT was stopped. Nowadays we have a better understanding and have better guidelines. Not only that we do it on the individualized basis. We use it only for short time, they don't exceed five years. So using HRT within five years is safe. So I would take some information from you and we will discuss about the risk factors and if you are a good candidates we can make a decision to prescribe it or not. Dr: What makes you interested in HRT? Patient: because of hot flushes. At this stage if the patient give you the symptom, it is your chief complaint. But if patient doesn't give you any symptoms, you should start with her LMP If she starts with the symptom of hot flushes, ask the patient 1.When did hot flushes start, 2.Is it all the time, 3.On & off or continues, 4.How many attacks, 5.Day or night, 6.How do you feel that you have it. 7.Night episodes, you have any night sweating, does it wake you up. Asked patient if the hot flushes wake her up during the night, and if she needs to change her gown of nights sweats. 1.Affect your sleep and how does it affect your concentration. 2.Change in your mood, anybody has told you that your short tempered, and if you 3. feel tired. 4. Some women with the same symptoms may notice some change in their sexual life. d)So the doctor should ask with whom do you live? e)Are you sexually active? f)Any dryness or pain during the intercourse? 8.Any change in your urination? Have you ever lost control? 9.Last period? •Are you periods regular or not? •If it's irregular, when did it start to become irregular? •Are your periods heavy or not? •Any clots? •*Any bleeding or spotting between periods? This is a very important point. 10.Bone pain? Any fractures? Any family history of osteoporosis? If yes, tell the patient that you will discuss this in another meeting. Because that's another session to discuss about using steroids, smoking, alcohol, caffeine, warfarin and diet. If she takes calcium supplements. MGOS for GYN cases: Menstural, Gynecologic diseases, Obstetrics, Sextually transmitted disease Dr: any history of gynecological disease like polyps, cysts, any pelvic intervention/instrumentation, surgeries. Dr: did you use to take any oral contraception? If yes, which one and did you have any side effects? Also you should ask about her last smear. Because she is 50+ you should ask about her mammogram. At any age you ask about Pap smear, once you reach 50 to ask about mammogram and when the patient pass 65 you should add bone density. You can ask about her obstetrics history, like have you ever been pregnant if yes how many times you have been pregnant? Now use the transition... Because this is the first time I met you, I would like to ask you about your past medical and social history. Is there any long-term disease, hospitalization before, any surgery, diabetes, or hypertension. Any history of allergy, and the medication she takes. ABCD: Active liver disease, vaginal Bleeding, Cancer, DVT For A you ask about any history of Active liver disease. Have you ever been yellowish? Any dark urine or pay stool? For B you should ask about any vaginal Bleeding? ... You have already asked these question before For C you should check about Cancer. I would like to ask about constitutional symptoms here to see if there is any endometrial cancer. Fever, chills, weight loss, appetite, lumps & bumps. A history of cancer in yourself or family (breast cancer, endometrial cancer,and colon cancer). For D you should ask about any history of swelling in the legs (DVT), any history of heart attacks, pulmonary embolism or stroke. Social history: smoking, taking alcohol, recreational drugs, how does she support financially herself, how does this affect her life and ask about osteoporosis.

Usually in this set of scenario, you tell her on the basis of the history you are good candidates for HRT. However as I told you it is an important information to tell you to make your decision. As we go through different stages of life usually for ladies, we go to the stage called menopause which is vary between person to person. At this stage there is hormonal changes and ovaries start to produce less hormones specialty estrogen and progesterone and that changes affect the whole body. It can explain about dryness, decreasing or absence of periods. And that's why we try to replace those decreased hormones by HRT. They are the same hormones but we give it through external sources either tablets or skin patches. As I told you before there is a balance it's your decision to make. And the balance is to use it up to five years. Using more than five years would increase the risk of stroke, heart attack or some cancers depending on what we call it estrogen dependent that includes breast and endometrial cancer. And some studies showed that it might increase the risk of Alzheimer's disease. So the risk of use for less than five years is not significant and still acceptable. So if you want to use it the shorter the better. To get rid off the hot flushes there are other measures like exercise or herbal supplements that you can try to improve the symptoms.

The HRTs are the same as OCP's but in smaller doses and you can take one tablet a day. They have a few side effects like weight gain, bloating, nausea, abdominal distention and pain but they improve by time. The serious side effects are headaches, swelling of the legs or chest tightness which whenever happen you should go to emergency room. By using these HRT's your periods may stop or you may see spottings. If the patient had hysterectomy before you only give estrogen without progesterone, otherwise you should give both. Because you take it regular shootout regular ultrasound scans to check the thickness of the endometrium and sometimes we should take a sample

INFERTILITY



(Sometimes it is not easy/Sometimes it takes time/I’m glad you’re here) Intro: As I understand you’re here because you’ve been to get pregnant for the last 14 mo, during the next few minutes tell me more about this difficulty. Did you seek medical attention before? (<35 –1yr/35 -40 6m0/>40 ASAP) PID & other med condts: ASAP How long have you been in this Relationship? How long have you tried? Have you ever been pregnant before? Have you ever had Mc or Abortion? Spouse: has he had children from a previous relationship? Let us talk about your Partner: (If less time Fast otherwise get details) Fast: Was he ever investigated? Did he have Semen analysis? What was his sperm count? Detailed: How is his health Does he have (Htn?DM/On meds) Any back trauma,back pain? Any Surgeries Any H/o mumps in childhood? H/O Ca, Rxt Cxt,STIs? Any Psy meds,Stress,travel a lot? Exposed to heat at work or recreational way? COITAL Hx Some qns about intimacy: How often do you have IC with husband? How do you monitor your temp? How do you measure your urine test? Is your husband capable of having an erection & ejaculation? Do you use any lubrication? MENSTURAL When was your LMP? GYN: SEXUAL: Any STIs Back to Content

16 YOF information about Pap Smear,



counselling, health maintaining issues (comes with HEADDSSS). Whenever there is counselling – take history. . Pap smear – What do you like to know about Pap smear? Usually we offer it for people who are sexually active, for that reason I’d like to know if you are in a relationship? Are you sexually active? When did you start? Any other relationships or partners prior? Do you use protection? What oprotection do you use? Any STD (blisters, ulcers, warts) in the last 6 mo? MGOS: M:LMP How often do you get your menses? Are they regular? Are your periods painful? Are they heavy? G – any gynaecologic disease? Any pelvic exam? O: Any H/o pregnancies/Abortions? Past medical Hx? HEADDSS .... Counsel about Seat belts Mood & Risks of suicide?

Counselling: Why? & How? I am glad you came here today to talk about Pap smear. As a matter of fact PS is one of the most successful screening tests to pick up one type of dangerous cancer called “Ca Cx” which is caused by a virus called Human Papilloma virus & a condom does not protect you from this. It is important to pick it up early, since by time it starts to give symptoms it is too late. Let me explain it to you. The area connecting the vagina to womb is called Cervix, & from the outside it looks like this:(Draw the circle with a dot) from this part we’ve to get a sample it gets infected with HPV virus which is similar to wart virus, but in the cervix, it leads to cancer. It should be done a week after your menses. It has to be done in a certain way, there will be a nurse with me,& you will be on your back, the exam bed has pedals to support your feet. We will use a speculum which come in different sizes & are plastic & disposable & we use a water based lubricant. If spatula rotate it to 360 & put on a slide, fix it & send to lab. If brush, rotate it 5 times put in fluid & send to lab. Results will be back in 2 weeks. If all is well, we will not contact you. PS has to be done every year .Once results are normal for 3 yrs & you’re with same partner you casn do it every 2 years till 69 years old, when you can stop ,If you change your partner, you’ve to do it yearly again. Other hazards – drinking and driving.



YOUNG WOMAN: ANTENATAL COUNSELLING



History Ask how Pt feels about being pregnant When did you do the test? How did you find out? Congratulate if she is happy. It is a very exciting time of your life. Ask questions about the pregnancy LMP: LLMP was it similar to prev menses or less bleeding? Calculate EDD; - 3mo + 7 days Sx:, N/V/Breast engorgement/Inc visits to washroom Rh status If nausea severe, ask about dizziness O: GTPAL Any complications in previous pregnancies: HTN/DM/Twins/Congenital anomalies G: (surgeries, infections, PAP’s) S: Any STIs PMH: Vaccinations, diabetes, hypertension, heartdisease, genetic diseases, kidney diseases, immunological diseases Past history of surgery-especially childhood Family Hx: Genetic disease, prematurity, early onset deafness SHx:Medications, Smoking, Alcohol, Recreational drugs OTC if on Aspirin ask to stop & change to Tylenol Social Hx: partner, support, provisions for child With whom do you live? How does your partner feel about this pregnancy? Do you feel safe in this relationship? Do you have pets? If has cat,not to change litter.

COUNSELLING:

I will confirm pregnancy by blood work Physical Investigations Vitals, weight, full exam including PAP smear (if not done in last 6 mo)and cultures CBC, Lytes, INR/PTT, Urea, Creatinine, Blood Type, VDRL, Rubella antibody, Serum folate, Hepatitis, +/- HIV, Urine dip and microscopy, ECG if indicated, +/- sickle cell and thalessemia screens. Nuchal Translucency at 12 weeks Maternal serum screen at 16 weeks Anatomy ultrasound at 18-20 weeks Glucose challenge test at 24 weeks +/- Rhogam at 28 weeks Diet, smoking, alcohol, exercise, medications, morning sickness Average weight gain is 25-35 lbs with 5-10ibs up to 20 weeks and then 1lb/week thereafter Risks of Down’s 1/200 at 35 Consult MD prior to meds For morning sickness eat bland foods, small portions, Diclectin is an option Hemorrhoids, back pain, heartburn and increased vaginal discharge are common Visits are every 4 weeks until 28 weeks then every 2 weeks Back to Content 19/2/2011 Introduction What to write on the note before entering the room: •Name •Age •CC •What required •DDx

First buzz – turn and read the stem (2m) Second buzz – knock the door and enter. The examiner might tell you that at the end he will ask you 1 or 2 questions. In the next buzz – it will be the time for the questions. If he doesn’t ask – complete the task. After another minute there will be a longer bip sound.

Short station (history, physical exam, s/e of psychiatric medications): 1.5 m buzz – enter Short buzz after 4.5 m (do “Thank you for the information, I’ll do the physical exam and I’ll take it from there.”

CC “As I understand you have ...for ... can you tell me more from the moment you started to notice it.” “I am glad you took the time to come here

In case of physical exam: Intro: name, position, why you are here, time that I am going to spend with you and for which purpose. “Good morning, my name is...I am the attending physician here. I understand you are here because....In the following 5 minutes I will perform physical exam, hopefully towards the end we will reach a workable plan. If you feel any discomfort please inform me. Do you have any questions?”

Imaging, blood work “Hello, good afternoon Mr. ... as I understand you are here to get your blood work results, since this is the first time I see you before I am discussing the results with you I have some questions to discuss with you.” Than: Why, 1st time, who and when. In case of breaking bad news: SPIKE Setting Perception (What is your understanding about the test, and why you are doing that” Invitation (How much details do you like to discuss with you? DO you like anyone to be with you?) Knowledge (What do you know about the condition?) Expectations (What are your expectations from today’s visit? What is your expectation from the result?) Gives the result.

Questions for telephone session: What’s your number? Where do you live? “...did I say it right?” Connecting with a colleague:

Psychiatry

Psychosis

1.55 yo, believe that have strange feeling in hands. Do mental exam. Either organic, late onset of schizophrenia, not complying with medication. 2.35 yo, believes that the RCMP chasing him. Persecutory delusions. Reassurance about his safety. DDx substance abuse. 3.24 yo, brought by his roommate because haven’t been himself in the last 10days. Can be acute psychosis, substance abuse, HIV, mania 4.30 yo, wants to arrange DNA test for his children. 5.17 yom, worried about contamination – wants to be admitted to get rid from it. 10min – councsel. 6.22yo, diagnosed with schizophrenia 6wk ago, concerned about his condition. Think about suicide! 7.17 yo male, pain in his neck. s/e of drugs. 8.35 yo, brought by the police because he wanted to slaughter his children (thinks he his Abraham). Ask him “Who is Abraham?” Ask early about: “How is your mood today?” – To differentiate from mania.

Mood (Presenting symtoms) MI PASS ECG 1.Low mood for the last 6w. 2.Patient with difficulty to sleep: 2.1.22 yof 2.2.35 yof 2.3.75 yof asking for sleeping pills 3.Suicide case. 4.Presentation with tiredness 34 yo. 5.40 yom hasn’t been himself for the last 3w – his wife concerned. 6.70 yo has back pain for 3w (x2 cases). 7.Dysthemia case. A young lady with low mood for years

DIG FAST 1.Impulsive behaviour – might be presented with intoxication to the ER. Sexual activity with no protection. Issues with the law (fighting in the bar, waking up the neighbours). 2.Grandiosity – some delusional ideas. 3.Patient who wants to discontinue the medication.

Anxiety 1.Panic attack – heart racing, sob, dizziness, tingling, numbness (hyperventilation – hypocapnea) STUDENTS FEAR 3C’s 2.Patient already diagnosed recently with PA or Panic disorder or generalized anxiety – discuss the treatment. Delirium and Dementia – Cognition disorders 1.57 yom difficulty with her memory. History and mental status exam (mini mental). 5min. 2.67 yof difficulty with her memory. Score for mini-mental 20. 3.67 yom came with his wife, concerned about his memory for the last 3m. Next 15min talk with him. 4.70 yom, s/p hip replacement 3d ago. Didn’t sleep last night (reversed sleep cycle) – delirium. Fragmented sleep cycle – dementia. 5.His dad is not being himself. You talk with the son. You cannot do mini-mental to the son. 6.Talk to the son about his mom that is in senior home. He is concerned – she was given 15u instead of 5u of Insulin. “It looks like there is some kind of medical error.”

Eating disorder, borderline, schizotypal, conversion



1.16yof, the parents concern that she loses weight. Part of the DDx is figure out that she has amenorrhea.

2.22 yof wants to be admitted. She wants to kill herself. If is the first time – you need to admit her. If it is several times – it’s not necessary to admit her. You have to finish the assessment. If she lives the room before finish the interview – you will write form #1. Usually people with psychiatry problem have: social worker and case manager. Have you ever seen by psychiatry. 3.Schizotypal disorder 4.Sudden loss of function. Seen by two doctors, one of them specialist in that field – it means it is conversion. 4.1.Loss of vision in her rt eye. Seen by ophthalm. 4.2.22 abdominal pain for 3w, seen by a surgeon a week ago. Counsel. 4.3.Headache for the last 6 mo, she wants to renew her thylanol 3 (x2) 5.Alcholism 5.1.AST>ALT, GGT elevated 5.2.His wife concerned he is not himself for the last 3m 6. Suicide (SAD PERSONS – score more than 4 you have to admit). 6.1. Overdose of aspirin. Medically clear.

Psychiatry Assesment



In PSY Ds look for: I.TIME II.CRITERIA If CC is psychiatric, make an early decision in MOAPS format, where: M=Mood Depression --MI PASS ECG •Mood How is your mood? Do you feel down? Do you cry a lot? Have you felt that before? “You look down for me – is there any chance you are depressed?” Is your mood always down or does it alternate? Have you been very happy at times? if YES: enquire about Mania

•INTEREST: Have you lost interest in activities in doing activities that were enjoyable to you? “Anything makes you happy?” If he doesn’t it any more – “Why?” (Doesn’t have time, no energy, or doesn’t enjoy it) •PSYCHOMOTOR RETARDATION/AGITATION: “DO you feel things are getting slower? Do you need more time to do things you did before?” •APPETITE “Did you lose weight deliberately?” •SUICIDAL Ideation “Any plan?” “Did you live a note?” “Did you start to give your belongings to others?” •SLEEP “When you go to sleep? When wake up? Do you feel fresh?” •ENERGY “Do you feel tired?” •CONCENTRATION “When you read an article can you finish it to the end?”

“Do you find to focus to concentrate in one subject?” •GUILTY “Do you feel guilty?” “Do you feel there is no hope in life?” After getting two depression episodes. If they are at least two month apart – Major depressive For teen age istead of mood and interest is replaced by irritability and droped in school performance. In elder person you might have need somatic disorders. Bipolar I (Mania) - DIG FAST (elevated mood + at least three out of the seven for a week) sometimes it is irritated mood – than you need 4 out of seven for a week. Usually they don’t last a week – so if they end up in hospital look for the criteria even for less than a week. •DISTRACTATIBILITY: “DO you find difficult to focus on one subject?” “Are you working on more than one project at the same time?” “How many projects do you work in?” – “Are you able to finish it or not?” •IMPULSIVITY “Are you spending more time than before?” “Are you borrowing money from other people?” “For what reason?” “Are you drinking more than before? Do you use cocaine? Which happen first? – elevation of mood or using cocaine?” “With whom do you live? Are you sexually active? How many partners do you have? Do you practice safe sex?” “Do you have any problems with the law? Speeding tickets? Any fights? •GRANDIOSITY: “Do you believe you’re a special person?” “Do you believe you deserve to be treated in a special manner?” “Do you feel you’ve a special power?” “Do you feel you’ve a special mission?--- if Yes Always ask what is the mission? & probe deeper & inquire about Delusions* • FLIGHT OF IDEAS: Do you feel thoughts racing in your head? Do people say you’re jumping from topic to topic • GOAL DIRECTED ACTIVITY: “How much time you spend in your activity?” •SLEEP •TALKATIVE “Anybody mentioned that you are talking faster or more than others?” Ask:If first episode or has it occurred before? Also look for OPPOSITE mood Relapse rate for the first time: 60% next time it is 80% third time 95%. Intro Why? Concern Assess mood today How you were diagnose with bipolar I? When? Why? Were there any serious consequences? Regular follow up? When you saw last your doctor? What was the level of Lithium that time? How do you feel about Lithium? Did you notice any s/e? Have you ever forget to take the drug? (It will be easier in the counselling). “I know that you have been this question before but I am going to ask you again – do you hear any voices. Do you worry a lot...” Counselling Compare mania to depression. What is your understanding of mania. It is a condition...

O=ORGANIC (I MAD): •ENDOGENOUS (ILLNESS); Depression: Hypothyroid/Lupus/Ca Pancreas/Post MI/CVA •EXOGENOUS: (Substances: MAD) M: Medications: Dosages/duration/SE/Toxicity A: Alcohol: How much/day? D: Drugs: 1.What drugs have you tried? 2.When 3.How much 4.Any Hx of O/D,W/d,SE,hospitalizations? 5.Which drugs NOW?

A=ANXIETY SCREEN: Do you worry a lot? Interview Questions to Establish Specific Anxiety Diagnosis Questions Further Inquiry 1.Do you have sudden episodes of intense anxiety? Establish nature of attack * 2.Do you have difficulty going to places to Inquire about crowded places, line-ups, which you used to be able to go? movies, highways, distance from home. 3.Do you have difficulty talking to people Establish situations (one-on-one or groups). in authority or speaking in public? 4.Are you afraid of blood, small animals or Establish precise feared situation. heights? 5.Do you repeat actions that you feel are Ask about washing, counting, checking and excessive? hoarding. 6.Do you have thoughts that keep going in Ask nature of thoughts (illness, harm, sex) your mind that you can't stop? Relieved by washing hands/praying. Do these thought cause stress for you? How do you relieve this stress? 7.Have you experienced any emotionally Establish the nature (accident, sexual, stressful events? torture) and timing of the trauma. When & What happened? 8.Do you worry a lot of the time? Ask about worries related to health, family, job and finances.

P=PSYCHOSIS HALLUCINATIONS: VISUAL HALLUCINATIONS: 1.Do you sense things that are not actually there? 2.Do you see things that others do not see? 3.What do you see? 4.Can you describe what you see? 5.Does it have a message for you? 6.Does the message ask you to harm yourself? 7.How do you feel about it? 8.Is this the first time? AUDITORY HALLUCINATIONS: 1. Do you hear voices other people cannot hear? OR : a)If you’re alone & nobody with you, do you hear voices? b)Do you hear voices inside your head? 2.How many voices? 3.Are the voices familiar? 4.Do you recognize the voices? 5.Do they talk to you? 6.Do they talk about you? 7.What are they asking you to do? 8.Do they ask you to harm yourself? 9.Do they ask you to harm anybody else? If YES: 10.What is preventing you from doing this?........Screens for INSIGHT

11.How do you feel about these voices? (“Some people feel comforted when they hear these voices, others feel threatened”). DELUSIONS:

1.Do you feel anyone wants to hurt you or harm you? If YES: WHO & WHY? 2.Anybody tries to control you? 3.Anybody wants to put thoughts into your head? (Thought Insertion) • Anybody wants to steal thoughts from your head? (Thought withdrawl) 4.Others can read your thoughts? (Thought broadcasting) 5.When you’re watching TV or reading the News, do you feel they’re talking about you? (Ideas of reference) 6.Do you feel any part of your body is rotting? 7.Do you feel everybody is falling in love with you? S=SELF CARE •HOMICIDE: •SUICIDE •SOCIAL HISTORY: oWith whom do you live? oHow do you care for yourself?

PAST PSY HISTORY: 1.Any similar Sx/Ds in past? 2.Any Other psy Sx/ Ds in past? If YES: 3.Analyse Sx/extent of incapacity/Rx recvd/names of hosp/Compliance PAST MEDICAL HISTORY: R/OAny medical illness:DM/HTN/Thyoriod/Surgery/Head trauma/HIV/AIDS/Syphillis SAD – Smoking, Alcohol. Drugs (especially long use of cocaine) Screen for anxiety – are you fear a lot? any fears, especially from open places? Screen for psychosis – “anybody wants to harm you? Sometimes people having similar experience – they might hear voices or see things other people don’t see. How about you?” FHx: •Anyone in family with similar Sx/Ds •Anyone in family with other pSy Sx/Ds •Drinking / hospitalized from psychiatry reason? •Relationships SADD FHx: •Suicide •Alcohol •Depression/Divorce/Drug PERSONAL Hx: 1.Prea-dulthood 2.Adulthood: Social activity: Support system, Friendships (depth/duration/Quality) isolated, asocial With whom do you live? If he lives alone – do you have any friends you talk with? Current Living Situation: Where/with whom/Relationships at home/financial support/Assistance OCCUPATIONAL HX: How do you support yourself? What are your ambitions/goals/relationships/Conflicts at work?/STRESSES/ Job changes MARITAL & RELATIONSHIP Hx; Age/Duration/areas of (dis) agreements,outcomes MILITARY Hx Gen Adjustement,combat,Injury Educational Hx: Highest grade/Area of interest Religion:Strict/Permissive attitude towards suicide

PSYSOCIAL Hx: Sx/attitudes/orientation/practises/STDs (HIV) 1.Are you currently in a relationship? 2.Are you sexually active? 3.Are you active with males, females or both? 4.How long have you been in the current relationship? 5.Are you practising safe sex? 6.Are you using condoms all the times or just sometimes? 7.Is there a risk for you to be at a risk for STDs like HIV/HBV/Syphilis? 8.How about your partner? 9.How about your previous partners? Or the previous partners of your partner? 10. Have you or your partner tested for HIV,HBV or Syphilis?/When/Outcome 11.Are you currently seeing anyone else? 12.What other relationship have you had in the past?/ Anytime with more than one person at a time 13.Have you ever paid/received money for Sex? Allergies

MSE/MMSE

APPEARANCE: 1.Well dressed 2.Well groomed 3.Dress matches weather 4.Given age matches chronological age BEHAVIOUR: 1.Agitated 2.Psychomotor retardation 3.Eye Contact 4.Co operative 5.Non hostile 6.No abnormal movts/Jerking/lip smacking C/SPEECH:

1.Volume 2.Tone 3.Fluency 4.Articulate MOOD& AFFECT: Mood;Subjective Sx in pts own words Affect (qarms) 1.Quality: Euthymic/depressed/elevated/Anxious 2.Appropiateness to thought content 3.Range:Full/Restricted/Flat/Blunted 4.Mood Congruence 5.Stability: Fixedt/Labile PERCEPTION: Hallucination Illusion THOUGHT PROCESS: Coherence/Incoherent Logical/Illogical Circumstantiality/Tangentiality THOUGHT CONTENT: • Suicidal/Homicidal Ideation 1.Low-- fleeting thoughts,no formulated plan,no Intent 2.Intermediate--More frequent ideation,well formulated plan,No active intent 3.High --Persistent ideation & profound hopelessness/Anger,well formulated plan,active intent,believes suicide,homicide is only helpful option available • Obsession: 1.Recurrent or persistent thoughts,impulses or images that cannot be stopped which is intrusive or inappropriate 2.Cannot be stopped by reason & Causes marked anxiety & distress • Preoccuption: •Overvalued Ideas: •Ideas of reference: •Delusions: •Magical thinking: •First Rank Sx of Shz:Thought insertion/T withdrawal/T broadcasting COGNITION: MMSE Level of consciousness Orientation in time/place/person Memory: immediate,remote,recent Attention & Conc Global evaluation of intellect: Intellectual Fns: INSIGHT: JUDGEMENT:

DELERIUM MMSE



1st reassuare the pt,calm him down talk & do MMSE O-O-O-O-O = 5 = Time: Year/Season/Month/Day/Date O-O-O-O-O = 5 = Place:Country/Province/City/Street/No O-O-O = Immediate recall:Black/Honesty/Tulip (if he makes mistakes,correct him but give _ve O-O-O-O-O = Concentration: Can you spell WORLD backwords? O-O-O = Delayed recall O-O-O = Comprehension: 3 step command O-O = Naming 2 objects (pencil & paper) O = Reading ; write a sentence: Close your eyes & ask him to follow the command O= Writing O = Repeating; No ifs ands or buts O= Copying

Why Delerium: Fever Ha/photophobia? Did you eat last night? Abdominal pain /Flank pain? Calf pain? Medications Alcohol (Last time & now) CSx: Ask examiner for I/O chart & medication chart

FORMS to Be filled:



If during an interview a pt decides to leave & not finished...... If pt wants to kill someone or himself....ADMIT If Pt refuses to be admitted & insists on leaving: INVOLUNTARY ADMISSION----------FORM 1 And another doctor must come & asses him. Cannot hold in hospital for > 72 hrs

If a wife /partner brings & dr assesses & there may be a chance that the Pt may commit suicide/homicide, pt can be sent home, on condition that if Pt detoriates she should call back & immediately & bring Can file FORM1

If pt refuses voluntary admission with first dr,but second D. Can assess & can discharge if he feels fit for discharge,or admit on VOLUNTARY basis Admission always better on voluntary basis

If second dr admits on involuntary basis it is FORM 3 & valid for 2 wks During these 2 wks,pt improves,& so can be discharged, or gets voluntary admission When admission voluntary --- FORM 4 Form 4 is renewed Released on --FORM 5 Thus FORMS 3 & $ are for Rx

PANIC Attack



ONSET: 1.When did it start 2.How did it start? 3.What were you doing at that time? COURSE:

1.Is the Intensity same now as it was when it all started? 2.How about the frequency? 3.What made you come in today? DURATION: How long does each attack last? PQRSTUV

1.Where exactly does it hurt you? 2.Can you describe the pain? 3.Does it move to anywhere else n your body? 4.On a scale of 1 to 10,wher 1 is mild & 10 is max,where would you rate this pain? 5.Has this affected your life in any way? 6.Is there a particular time it comes on? 7.Did you ever have this before? AAA

Alleviating Fcts: What makes it better? What Aggravates it? 1.Exercise 2.Stress 3.Certain situations or places? 4.Coffee? 5.Medications?

6.When passing urine or having a bowel movt or cough? ARE YOU AFRAID THAT AN ATTACK IS COMING? Assoc Sx: first R/o cardiac then GI & then shift to Psy •N/V/Diarrhoea •Heart racing/ Sweating/ Dizzy •Decreased wt & Increased appetite/ Tremors •Headache •Tingling & Numbness •Nervous & Out of control •Do you feel you’re going to die? •During these attacks do you feel things are unreal? •During these attacks do you feel you can see yourself? •Do you feel you’re going crazy? •Do you feel worried about being in places or situations where escape might not be possible e.g: Crowded places Closed spaces If YES: *What place or situation? *What happens in such a situation?

*How has it impacted your life? *How have you dealt with this issue? Here ask for anxiety disorder: Are you a person who worries a lot? Interview Questions to Establish Specific Anxiety Diagnosis Questions Further Inquiry 1.Do you have sudden episodes of intense Establish nature of attack anxiety? 2.Do you have difficulty going to places to Inquire about crowded places, line-ups, which you used to be able to go? movies, highways, distance from home.

3.Do you have difficulty talking to people in Establish situations (one-on-one or authority or speaking in public? groups). 4.Are you afraid of blood, small animals or Establish precise feared situation. heights? 5.Do you repeat actions that you feel are Ask about washing, counting, checking and excessive? hoarding.

6.Do you have thoughts that keep going in Ask nature of thoughts (illness, harm, sex). your mind that you can't stop? 7.Have you experienced any emotionally Establish the nature (accident, sexual, stressful events? torture) and timing of the trauma. 8.Do you worry a lot of the time? Ask about worries related to health, family, job and finances.

a. MOAPPS

MOOD RISK FCTS: To gain more insight into your condition, I need to ask some questions about your personal life : Do you:

•Smoke •Take alcohol •Recreational drugs (in case of cocaine – ask if sniffs or injects it. If injects – continue by r/o HIV symptoms) •Are you on any medications? •Did you take anything for a cold or flu • Are you taking OTC products/herbal remedies? •Are you allergic to anything? •When was your last period?

Are you going through a stressful situation in your life? How are you coping with it? FAMILY H: Does anyone in your family have a similar condt? SOCIAL H: COUNSELLING: From what you’ve told me, your chest pain seems related to a condition called “Panic Attack” It is a fairly common condt It's not known what causes panic attacks or panic disorder. Things that may play a role include: • Genetics •Stress

•Certain changes in the way parts of your brain function Some research suggests that your body's natural fight-or-flight response to danger is involved in panic attacks. For example, if a grizzly bear came after you, your body would react instinctively. Your heart rate and breathing would speed up as your body prepared itself for a life-threatening situation. Many of the same reactions occur in a panic attack. But it's not known why a panic attack occurs when there's no obvious danger present Nonpharmacologic Choices •Caffeine or other stimulant use should be reduced and controlled. •Alcohol use should be minimal; it should not be used to control anxiety. •Reduce the “as-needed” use of short-acting benzodiazepines as much as possible; ideally, such use should not be continued for longer than 4 days. •Stress reduction, including relaxation training and time management, is often helpful initially. • Specific cognitive behavioural therapy (CBT) may be required;

he selective serotonin reuptake inhibitors (SSRIs) citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline are all effective in reducing panic SSRIs and SNRIs have become first-choice agents in treating panic disorder with or without agoraphobia.2There is usually a delay in response to these agents that may be accompanied by initial agitation. Combining the SSRI or SNRI with a brief course of low-dose benzodiazepine augmentation therapy (i.e., no longer than 8 weeks) can increase adherence to medication and produce a more rapid response than with antidepressants alo

Panic Disorder with Agoraphobia

The pharmacologic treatment of panic disorder with agoraphobia is the same as for panic disorder. However, much of the disability in panic disorder with agoraphobia arises from the avoidance behaviour rather than the panic attacks. This can be addressed with cognitive behavioural therapy (CBT), even if medication reduces or eliminates panic attacks. CBT can be more effective alone than when it is combined with medication.8 However, access to specialized CBT is often limited.

Personality Disorders



“Am I crazy?” “There is no medical condition called like that, however sometimes patient have some difficulties with their thoughts and reality, it is called schizophrenia.” Mental Status Exam: Appearance wise...dressed, gromed Behavioral wise: Speach wise: Mood wise: Perception: Thought processing: Thought content: Judgement:

Mini-Mental: delirium, dementia, post-concussion



Writing a chart (SOAP):

Subjective Objective Assessment Plan

Borderline Personality

Work on this event and previous attempts.

If she was diagnosed – “have you ever seen by psychiatrist? What was the diagnosis? What you didn’t contacted your case manager/psychiatrist? ER or ICU or Weapons? In Toronto – contact with the case manager/psychiatrist. What is the trigger that makes her come today? In case of crisis – do you have anybody to contact? Refer to crisis team/Social worker/ “In order to determine if I can admit you or not I need more information... Always the same pressure like today? If the patient mentions work – “what do you do for work?”

Anything happen recently? Have you had any other relations? Is it difficult for you to maintain relation? Mood, Anxiety, Drugs/Alcohol/

22 yo wants to be admitted.

Borderline personality

When Pt wants to be admitted she may say,if you do not admit her,something bad may happen like last time. Pick up early when she says this ...... Start with EVENT: Check previous attempts at suicide Pick up early when she says something bad happened Ask: WHAT happened? If Suicide attempt....... 1.When & How many times before

2.Was she seen by psychiatrist? 3.Has she been to ER before? 4. Was she diagnosed & Rxed 5.Why can;t she contact her psychiatrist? 6.Was she admitted in ICU? 7.Which Rx programme does she have? 8.Does she have a crisis team & case manager? 9.Why didn’t she contact them? If repeated attempts at suicide: Which treatment programme does she have? Is admission one of it? CRITERIA FOR BPD: •Fluctuating mood either very happy or sad •Splitting

•Feeling of emptiness •Failure in maintaining a relationship both on social & employment areas •Impulsivity Drugs & Sex •Was sexually abused as a child Let her go or admit 1st episode admit needs Psy assessment Look for TRIGGERS that made her come in today Do not let her manipulate you I really like to help you,I’m on Er duty My job is to asses you & admit you Once admitted another Dr will asses you

•Can you tell me why you want to be admitted? •I really want to help you... •What bad thing will happen?

In order to admit you or not, I need more info & therefore I need to ask you, & admitting you is one option

If pt says Something Bad will happen o What do you mean? o When did it start? o Did it happen before? o How many times before?

NO EMPATHY

When did it happen the 1st time? When was the last time? What was done? Were you admitted to ICU? In addition to slashing your wrists have you used any other methods?...Like weapons or medications?

Pt says she feels some pressure Ask if the pressure felt today is the same as the pressure felt last time I want to help you looks like the last few days were stressful Have you been seen by Psy? What was the diagnosis? Do you still see the Psy?

When was the last time you saw him/Her? Why did you stop? What medication were/are you taking? In addition to psy is there a case manager? In case of crisis do you have anybody to talk to/ or contact? What prevented you from talking to them today?

Ask prior to Event?

What happened 6 wks ago? How did you lose your job?

What sort of job were you doing? What happened? Prior to that what sort of job were you doing? Is it difficult for you to stay in one job? Have you tried to find another job? Anything happened last night? If Boy friend left her.....How long have you been together? How does she feel about it? Was he supportive? At what age was she sexually active? Does she find it difficult to stay in a relationship? MOOD

DEPRESSED: Ask for HOMICIDAL ideation Manic Ask Drugs/Spending/Impulsivity ANXIETY After boyfriend ask about fly support...... Back to Content  

Depression



Sleep

If comes Tired  Sleep  Energy  Mood Sleep – how does it affect you? DO you feel tired? •―During the past month have you often been bothered by feeling down, depressed or hopeless?‖ •―During the past month have you often been bothered by little interest or pleasure in doing things?‖

MI PASS ECG

(TO diagnose depression – needs 5 out of the 9, in which one them should be either M or I. In teenagers irritability can replace either M or I, in elderly it can come with a somatic presentation) If it is one episode it is called: Major Depressive Episode (need 2w in which most of the days with depressed mood, and 4 more criteria). If there are 2 or more MDE within the same 2m – it is Major Depressive Disorder, if it is more than 2m – it is Recurrent Major Depressive Episodes.

M

How do you feel recently? How is your mood? Any chance you are depressed?

I

What do you enjoy doing? Are you still enjoy hobies? Anything brings happiness to you? Why don’t you enjoy any more? No time? No energy?

P

Do you think things are getting slower? Do you think you need more time to do things you used to do before?

A

Any change in appetite? Did you lose weight? How much weight did you lose? Was it intentional or not?

S

How about sleep? How many hours do you sleep? When do you go to bed? How long before you fall asleep? DO you wake up at night? Why do you wake up at night? DO you feel refreshed at the morning?



S

Do you feel any chance that you might harm yourself, end your life, or any ones? If patient says I wish I am dead, consider either he has only a feeling or a plan (active) Do you have a plan? What is preventing you? Did you leave a note? Did you start giving your belongings to others? (These are definite questions for a plan)

E

DO you feel tired? C Do you find it difficult to focus on a specific task (for example if you are watching TV – you can stick to the same program all through? Can you finish an article?)

G DO you feel there is no hope in your life? Do you feel guilty?

Regardless of any specific psychotherapy, measures to enhance treatment compliance are useful; e.g., providing psychoeducation with the following 5 simple messages is effective:19 •Take medication daily

•Call this number for questions about side effects or other issues •Remember that it might take 2–4 weeks to see a noticeable effect from antidepressants •Continue to take medication even if you are feeling better •Do not stop taking the antidepressant without checking with the physician

42 yom hasn’t been himself, his wife arranged for the meeting.



INTRO: As I understand you’re here today,as your wife has some concerns about you. Can you tell me more about it?

Give confidentiality. Counseling (last 2-3m): Based on what you told me your symptoms are consistent with a condition called “depression.” We believe it is caused because of imbalance in some of the chemicals in the brain. Sometime there is an event in life or cause that triggers that situation. It is common and treatable. We need to r/o other causes – and for that we need to do some blood work. What did I do wrong to feel so depressed? Depression does not occur because someone has done something "wrong". Like any other medical illness, depression is caused at least in part by biochemical changes in the brain, which lead to depressive symptoms. This is why medications which help correct chemical imbalances in the brain relieve depression. In fact, if a chemical imbalance is not present, antidepressant medications will not have any effect - they will not make a person "happy" when they are not clinically depressed.

How long before I feel better? Generally speaking, people will start to notice improvement in symptoms such as sleep disturbances or crying spells and energy levels a few weeks after starting their treatment. Improvement in depressed mood is usually slower, and it may take six to eight weeks before people notice they are feeling much less depressed. If someone has not improved after three to four weeks of therapy, the dose of the initial medication may be optimized, a different drug may be added, or the initial drug may be substituted. Up to 80% of people with depression do get better with the right medication. Will my depression come back?

The likelihood of depression recurring depends on how many previous episodes you have had. For people who are experiencing their first depression, the likelihood of having a second episode is around 50%. For people who've had two depressive episodes, chances of having a third are around 70% and for Those who've had three and more episodes, all but 10% will experience further illness.

Having someone else in your family who has depression makes it more likely your own depression will recur. Other risk factors for recurrent depression are the presence of chronic medical problems, a history of early trauma or abuse, dysthymia, onset of depression younger than 25 years or older than 60 years, and a long pattern of negative thinking, low self-esteem and relationship difficulties. A depression which does not completely resolve with treatment, as well as severe depression, also increase the likelihood depression will recur. This is why most people with depression need to be treated for at least six to nine months to prevent relapse, and for greater than 12 months if someone is being treated for a recurrent episode. Depending on the likelihood of depression recurring, some people stay on the same dose of their medication for long-term maintenance therapy. The saying doctors have is, "The dose that gets you well is the dose that keeps you well" and people will do better over the long run if the same dose is used throughout. Can I pass depression on to my children?

Certain types of depression, especially, bipolar affective disorder, would appear to run in families. However, even identical twins do not share an equal risk to develop depression, and depressive illness appears to be a combination of vulnerability to depression (part of which may be inherited but not necessarily), difficult life events and biochemical imbalances in the brain. I have trouble reaching orgasm now that I'm taking an SSRI. Can I stop my medication on weekends to improve my sexual function?

Some doctors recommend drug holidays where people stop taking their medication on the weekend. The biggest concern about stopping and starting medication revolves around compliance issues, but there is some evidence that people may not respond as well to the medication if treatment is continuously interrupted. For these reasons, drug holidays are not recommended and an alternative antidepressant or an additional medication to offset unwanted sexual side effects are better solutions. Regardless of any specific psychotherapy, measures to enhance treatment compliance are useful; e.g., providing psychoeducation with the following 5 simple messages is effective:19 •Take medication daily •Call this number for questions about side effects or other issues •Remember that it might take 2–4 weeks to see a noticeable effect from antidepressants •Continue to take medication even if you are feeling better •Do not stop taking the antidepressant without checking with the physician

There are good options to treat it. If you choose to go to talk therapy I can refer you to a psychology. On the other hand we can use medications which are generally safe. Called SSRI similar to Prozac, however like any other medical intervention have some side effects. Most of them are minor, usually improve with time – headache, sexual...however the improvement of your mood will lag behind your improvement in your energy, we call that the window gap, and this is of concern to us. All contracts are verbal, besides the drug contracts – “I promise I will not use ...again...”

Mania



DIG FAST For diagnosis we need elevated mood + 3 criteria of the above 7 for a whole week. Sometimes irritable – you need 4 criteria. D DO you find it difficult to focus on one subject? Are you working on more than one project on the same time? How many projects are you working on? Can you finish it on time?

I Are you spending more money than before? Are you borrowing money from others? Are you maxing out on your credit card? Do you drink alcohol? Are you drinking more than before? DO you smoke or take recreational drugs? (If taking recreational drugs – feeling high) If taking cocaine – what happened first: the episode or the taking the drug? With whom do you live? Are you sexually active? How many partners have you had recently? Have you used protection? DO you have any problems with law? Any speeding tickets? Any fights?

G

DO you feel you are special? Do you feel you deserve to be treated differently? DO you have special powers? Do you have special mission?

F

DO you have thoughts racing in your head? What kind of thoughts? A How much time do you spend in your activities? S Lack of sleep? T Did anyone tell you that you are talking faster than before? Manic

1 Manic episode = Bipolar I Ask if it is the first time or has it happened before. How about the opposite. Have you ever felt high? Greater than 7 days in a row? Insomnia in elder

Difficulty in sleeping for 6 months Can you tell me more about it since it started? Did you seek medical attention? OCD Anything at that time? From that time till now – every night? When do you go to bed? Whe do you fall asleep? When do you wake up?

Before you fall asleep what do you think? What comes to your mind? When you sleep – do you wake up? Any nightmares? If she says she has to wake up for breakfast ask why she has to wake up? How old is your son? Has he been always with you or is he left and come back? Can’t the prepare breakfast for himself? Anybody else at home? How about your husband? CSx PMHx SHx How does son support himself?

Is he under stress? What is the nature of your relationship? Give confidentiality? How do you support yourself financially? Any financial concern? Ask if son contributes to finances? If son consumes Alcohol? (How much? Does he loose control/shouts?) Does he get angry to swear to get physical? Does he get accesses to your finances?

Did you talk with anybody about it? Do you feel safe going back home? Does he have access to fire arms? DO you have suicidal or homicidal ideation? Based on what you told me – your sleeping troubles seems to be related to stresses in your life called ―Elder Abused‖ which is illegal and crime against law. It is nor your mistake and you should not accept that. You need to call the police. From studies it has shown that police interevention improves such situations.

Son needs help – can you convince him? Police will protect you and son will be sent to rehab and anger management. I’ll be giving you sleeping pills for three days and f/u within 3d.

  Marijuana Counselling



(Mother comes in to see you as she has discovered Marijuana in her son’s belongings) INTRO: As I understand you’re here because you’re concerned about your son.

What is his name?

What is your concern? How much did you find? Did you ask him about it? •WHAT MAKES YOU BELEIVE IT IS MJ ? Is he using it? Or Is he carrying it? Is it the first time you’ve found it?

•Did you notice any CHANGES in his behaviour? Is he excited? Laughing out of nowhere? Is he preoccupied?

Does he stare at a wall? Does he talk to himself? Is he aggressive? Any problems with the law? Any fights? Any criminal records? Is he more isolated?

•How is his MEMORY? Is he more forgetful/lose his stuff? Does he take more time to react? Does he spend more time in his room? How much time do you spend with him? How much time is he out of the home? How much time does he spend with his friends? Do you know any of his friends? What kind of activity are they involved in? •Does he have a lot of MONEY?

Does he ask for money? Do you believe he steals money? Do you think he smokes/or drinks alcohol? •How would you describe his MOOD? Is he depressed? Is he still interested in his hobbies? Does he worry a lot?

Does he have excessive fears & avoid situations? Do you have concerns that he may harm himself or anyone else? EDUCATION: How is he doing in school? Have his grades dropped? DIET: How is his general health? Have you ever seen a psychiatrist? Fhx: SAD COUNSELLING:

Based on what you’ve told me.There are no changes in his health & behaviour (assumed that there were no changes in behaviour as per mum) When it comes to Marijuana it is a commonly used drug by teenagers, sometimes only once for experiment. When we talk about Substance Abuse & drugs we talk about different categories.

Marijuana is a SOFT DRUG,others like: Coccaine,Heroin& Amphetmanies are HARD DRUGS Let us talk about Marijuana first. It is from the Cannabis family & affects the brain by feeling happy, excited & enhances experience.Sometimes with prolonged use or in high doses can cause side effects including apathy. It interferes with memory,& can interfere with his studies & function & fine motor skills & may not be able to operate machinery It impairs judgement & he might take risks. Can cause Lung cancer

In some teens,in high doses unmasks schizophrenia & cause psychosis Interferes with sexual function & can cause infertility & weight gain By itself marijuana is not strongly addictive & hence he can stop it at any time with help.One of the concerns of Marijuana though is it acts as a bridge to Hard drugs which are addictive i.e you’ve to increase the dose to have the same effect,which is called “TOLERANCE”,& then one cannot stop the drug as it causes withdrawal . It is a crime to use,hold hard drugs.People can lose their jobs. If injected increases risk of HIV,Hepa B & C PLAN If you like,bring your son here I can talk to him. It is better to be a confidante to him. Try to be close to him, someone he can trust & can talk to.Try to make sure who’re his friends,& make sure you know what he is doing.Keep him busy with activities. If there are any druh prevention programmes in your community or his school,get him to attend them & gets the knowledge.

In case of the resident who was asked to backup his supervisor orthopaed 4.I am competent – to emphasize 5.Short term – we don’t have time so we need to see her urgently 6. Long term – solve the situations that it wouldn’t occur again

INSOMNIA:



The Sleep History 1.Time data (can also be collected as part of a sleep diary – 1. Did you nap or lie down to rest today? If yes, when and for how long? 2.What time did you go to bed last night? 3.What time did you put out the lights? 4.How long did it take you to fall asleep? 5.How many times did you awaken last night? 6.How long was your longest awake period; when was it? What time did you finally awaken? 7.What time did you get out of bed? 8.How many hours sleep did you get last night?

2.Questions about the sleep period 1.Do physical symptoms, such as pain, prevent you from falling asleep? 2.Do mental or emotional symptoms (e.g., worry or anxiety) prevent you from falling asleep? 3.When you awaken during the night, what awakens you? (Snoring? Gasping for air? Dreams/nightmares? Noise?)

4.When you get up for the day, do you have any symptoms? (Headache? Confusion? Sleepiness?) 3.Questions for the patient's bed partner 1.Does your partner snore, gasp or make choking sounds during the night? 2.Does your partner stop breathing during the night? 3.Do your partner's legs twitch, jerk or kick during the night? 4.Has your partner's use of alcohol, nicotine, caffeine or other drugs changed recently? 5.Has your partner's mood or emotional state changed recently? 6.What do you think is the cause of your partner's sleep problem?

Hygiene Guidelines

1.Keep a regular sleep–wake schedule, 7 days per week. 2.Restrict the sleep period to the average sleep time you have obtained each night over the preceding week.

3.Avoid sleeping in, extensive periods of horizontal rest or daytime napping; these activities usually affect the subsequent night's sleep. 4.Get regular exercise every day: about 40 minutes of an activity with sufficient intensity to cause sweating. If evening exercise prevents sleep, schedule the exercise earlier in the day. 5.Avoid caffeine, nicotine, alcohol and other recreational drugs, all of which disturb sleep. If you must smoke do not do so after 7:00 p.m. 6. Plan a quiet period before lights out; a warm bath may be helpful. 7.Avoid large meals late in the evening; a light carbohydrate snack (e.g., crackers and warm milk) before bedtime can be helpful. 8.Turn the clock face away and always use the alarm. Looking at the clock time on awakening can cause emotional arousal (performance anxiety or anger) that prevents return to sleep. 9.As much as possible, keep the bedroom dark and soundproofed. If you live in a noisy area, consider ear plugs. 10.Use the bedroom only for sleep and intimacy; using the bed as a reading place, office or media centre conditions you to be alert in a place that should be associated with quiet and sleep. If you awaken during the night and are wide awake, get up, leave the bedroom and do something quiet until you feel drowsy-tired, then return to bed. Note: Pharmacologic (or any) interventions will be less effective if these guidelines are not followed. In mild cases of insomnia, sleep hygiene guidelines, practised consistently and together, may be sufficient to reinstate a normal sleep pattern.

Difficult sleeping for the last 3m OCD How did it start? Suddenly / Gradually? From that time is it all the time or “on and off?” Shift to “whom do you live with?” U: How did that lack of sleep affect your life? Give confidentiality. R/O: Depression,

Drinking (her or husband), “How much? How often? Does he drink more? What is the reason? Any change in your life? When your husband gets angry – does he start shout at you? (“Sometimes when people are drinking it can

Did you go to the ER? How often you go to the ER? Did he ever shout at you? Does he swear?/Shout?/Call your names? How does it affect your self esteem? Did he ever become anger to the extent that he becomes physical? Pushing? Did he ever force you to have sex against your will? Did he ever hit the children? Did he ever abused you in front of the children? Who’s controlling spending? (If she says that the children are safe – you can say that children are smart and realize that).

Counselling

Based on what you told me it is called “spouse abuse” it is illegal, it is a crime and against the law. You shouldn’t feel guilty about that. We know from studies that this situation will deteriorate, and without proper of help it might end badly. If you are concerned with the economic situation I’d like to know that there are a lot of resources. I’ll give the number of social support that We know from studies...he will have some restraining...usually situations might improve. Always give them follow up in three days. Back to Content 55 yo, believe that have strange feeling in hands. Do mental exam. Either organic, late onset of schizophrenia, not complying with medication INTRO: 3 ways: 1.How did it start?

OCD:

What were you doing at that time? What happened at that time?

Ms Franco 55/F strange feeling in (R) hand x 6 mo in ER talk to her for 10 mins Can U tell me about it? Is it one or (B) hands? How did it start? Right now,how do you feel/ Right now u look concerened,anything bothering U? U’re in the right place

What were U doing when it all started? Anything special happened at that time? Ask What events?....... Or Do you remember how it started 1st time? Is it all the time or off & on Any particular time of the day Any particular settings What is special in that setting? In your opinion what is responsible for it? May show a pic

It may be like a radiation for you,but not for me Where exactly do you feel it?

Anywhere else?Any weakness/numbess Ask for HOMICIDAL/SUICIDAL ideation Ask for Hallucinations: P=PSYCHOSIS

HALLUCINATIONS:

VISUAL HALLUCINATIONS: 9.Do you sense things that are not actually there? 10.Do you see things that others do not see? 11.What do you see? You look preoccupied REASSUARE HER THAT SHE IS IN SAFE PLACE

DO NOT LOSE NERVE

12.Can you describe what you see? 13.Does it have a message for you? 14.Does the message ask you to harm yourself? 15.How do you feel about it? 16.Is this the first time? AUDITORY HALLUCINATIONS: 12.Do you hear voices other people cannot hear? OR : c)If you’re alone & nobody with you, do you hear voices? d)Do you hear voices inside your head? 13.How many voices? 14.Are the voices familiar?

DO NOT LOSE NERVE

15.Do you recognize the voices? 16.Do they talk to you? 17.Do they talk about you? 18.What are they asking you to do? 19.Do they ask you to harm yourself? 20.Do they ask you to harm anybody else? If YES: 21.What is preventing you from doing this?........Screens for INSIGHT DELUSIONS: 8.Do you feel anyone wants to hurt you or harm you? If YES: WHO & WHY?

9.Anybody tries to control you? 10.Anybody wants to put thoughts into your head? (Thought Insertion) • Anybody wants to steal thoughts from your head? (Thought withdrawl) 11.Others can read your thoughts? (Thought broadcasting) 12.When you’re watching TV or reading the News, do you feel they’re talking about you? (Ideas of reference) 13.Do you think any part of your body is rotting? 14.Do you feel everybody is falling in love with you?

MOOD

ORGANIC: Since it is first time I’m seeing you.I’ve to ask you questions Any long term diseases?

Look for S/e of meds (Streoids,smoking,drugs) Head Injury Fever Csx: Look for Social Hx Past Psy Hx Self Care

Admit

If Pt asks: Am I crazy? Thre is no medical condt called crazy.Sometimes some pts have difficulty in handling their thoughts & this is called “Schizophrenia” MSE

APPEARANCE: 1.Well dressed 2.Well groomed 3.Dress matches weather 4.Given age matches chronological age BEHAVIOUR: 1.Agitated

2.Psychomotor retardation 3.Eye Contact 4.Co operative 5.Non hostile 6.No abnormal movts/Jerking/lip smacking C/SPEECH: 1.Volume 2.Tone 3.Fluency

4.Articulate MOOD& AFFECT: Mood;Subjective Sx in pts own words Affect (qarms) 1.Quality: Euthymic/depressed/elevated/Anxious 2.Appropiateness to thought content 3.Range:Full/Restricted/Flat/Blunted 4.Mood Congruence 5.Stability: Fixedt/Labile PERCEPTION: Hallucination Illusion THOUGHT PROCESS:

1.Coherence/Incoherent 2.Logical/Illogical 3.Circumstantiality/Tangentiality THOUGHT CONTENT: •Suicidal/Homicidal Ideation Low-- fleeting thoughts,no formulated plan,no Intent

Intermediate--More frequent ideation,well formulated plan,No active intent High --Persistent ideation & profound hopelessness/Anger,well formulated plan,active intent,believes suicide,homicide is only helpful option available • Obsession: Recurrent or persistent thoughts,impulses or images that cannot be stopped which is intrusive or inappropriate Cannot be stopped by reason & Causes marked anxiety & distress • Preoccuption: •Overvalued Ideas: •Ideas of reference: •Delusions:

•Magical thinking: •First Rank Sx of Shz:Thought insertion/T withdrawal/T broadcasting COGNITION: MMSE Level of consciousness Orientation in time/place/person Memory: immediate,remote,recent Attention & Conc Global evaluation of intellect: Intellectual Fns: INSIGHT: JUDGEMENT:

24 yo, brought by his roommate because hasn’t been himself in the last 10days.



D/d: 1.Ac. psychosis, 2.Substance abuse, 3.HIV, 4.Mania If started 10 days ago, why brought in today? (could’ ve been homicidal or suicidal) If carrying a book, ask Reason Ask Delusions for grandiosity :“Do you feel you’ve a special mission?--- if Yes Always ask what is the mission? & probe deeper & enquire about Delusions Mission imp May be Suicidal or Homicidal ideation



  17/M worried about contamination – wants to be admitted to get rid from it. 10min – counsel



Delusions: Dd: 1.Schizophrenia 2.Schiziod personality Disorder 3.Schizotypal PD 4.Isolated PD (older pt in 40s & usually delusions about fidelity)

Qns about Delusions DELUSIONS: 15.Do you feel anyone wants to hurt you or harm you? If YES: WHO & WHY? 16.Anybody tries to control you? 17.Anybody wants to put thoughts into your head? (Thought Insertion) • Anybody wants to steal thoughts from your head? (Thought withdrawl) 18.Others can read your thoughts? (Thought broadcasting) 19.When you’re watching TV or reading the News, do you feel they’re talking about you? (Ideas of reference)

MOOD:

How is your mood,is it down,Up or N ? ORGANIC:R/O Head Injury CSx: HIV/Meningitis Medications: Steroids,smoking,alcohol,drugs S/e of meds,Pt may have stopped anti psychotics due to Se

35 yo, believes that the RCMP chasing him.



Persecutory delusions. Reassurance about his safety. DDx substance abuse. INTRO;

Early on reassure pt that this is a safe place, & invite him to sit down As I understand you’re here because you have worries that the RCMP is chasing you. I want you to know that this is a safe place & please come & sit. I want to help you so please sit down Make sure he sits in front of you. Ask him:

•Why chasing? •How long chasing? •How affecting him? •How does he handle it? •Does he talk to anyone about it?

Here there is persecutory delusion Besides police does anyone else want to hurt him? Does he have special powers? FINISH the delusions Go to Hallucinations VISUAL HALLUCINATIONS: •Do you sense things that are not actually there? •Do you see things that others do not see? •What do you see? •Can you describe what you see?

•Does it have a message for you? •Does the message ask you to harm yourself? •How do you feel about it? •Is this the first time? AUDITORY HALLUCINATIONS: •Do you hear voices other people cannot hear? OR : •If you’re alone & nobody with you, do you hear voices? •Do you hear voices inside your head? •How many voices? •Are the voices familiar? •Do you recognize the voices? •Do they talk to you? •Do they talk about you? •What are they asking you to do?

•Do they ask you to harm yourself? Also ask for tactile hallucinations I see you’re scratching your hands Any other areas are scratching? When & How long?.....Pt will answer.... I do not know ....... Jump to cocaine

Do you smoke/Take alcohol/Drugs I f Pt stands, you stand, reassure him & bring him back & ask again about drugs Did you take an increased amt recently? How do you take it? Snort/Smoke/IV? If IV ask about CSx; MOOD R/o Mania & depression Suicide & Homicide If Pt leaves tell I want to file form 1 & call security

17/M worried about contamination – wants to be admitted to get rid from it. 10min – counsel



Delusions: Dd: Schizophrenia Schiziod personality Disorder Schizotypal PD Isolated PD (older pt in 40s & usually delusions about fidelity)

Qns about Delusions MOOD: How is your mood,is it down,Up or N ? ORGANIC:R/O Head Injury CSx: HIV/Meningitis Medications: Steroids,smoking,alcohol,drugs S/e of meds,Pt may have stopped anti psychotics due to Se

•A key feature of bipolar disorder is recurrent nonadherence to medication; including the patient in decision-making, together with psychoeducation, promotes a strong therapeutic alliance and enhances medication adherence. •Patients taking lithium need to maintain their usual salt and caffeine intake and monitor fluid intake and output, making adjustments in the event of unexpected losses due to vomiting or diarrhea.

•During acute manic episodes, patients may exhibit increased tolerance to lithium. •Advise patients taking antipsychotics about antipsychotic-associated body temperature dysregulation and strategies to prevent heat stroke (e.g., hydration, sun protection). •For lithium-associated cognitive impairment, check lithium level and thyroid function. Lowering the dose or using a slow-release formulation may improve cognitive function. •Patients who experience tremor while taking lithium may benefit from elimination of dietary caffeine, lithium dose reduction or addition of a beta-blocker such as propranolol or atenolol. •Patients who experience diarrhea while taking slow-release lithium preparations may fare better with immediate-release formulations,17 particularly the oral liquid citrate salt.18

Pt wants to discontinue his Li If stop Li Relaspe 1st time: disct Rx:40 – 60 % 2nd time:80% 3rd time:>95% Can control BP1 but not cure

 

Want s to stop Li as handwriting not like before



Ask if any other concerns .....

Seems reasonable.... INTRO:

As I understand, you’re her cuz you’ve been diagnosed with BP1 3 yrs ago & want to disct your Rx,during the next few minutes I will take Hx & towards the end hopefully we will reach a working plan Ask: Why do you want to discontinue? ASSES: MOOD disorder whether Mania/Depression Go back to mania specially when diagnosed Li if SE Asses: Psychosis Anxiety Organic

Past Medical Hx Fhx Social Hx Fhx of Depression & BP1 Suicidal 7 Homicidal ideation Self care COUnselling

INTRO

Can you tell me more about your decision? Why? Any other reasons? These seem reasonable enough concerns & I’m glad you’re here today to talk about it Let me ask some qns How would you describe your mood today? Even if he says good..... Go through DIG FAST Grandiosity:

Ask for opposite mood Do U feel Low MI PASS ECG 1.How were U Dsed as BP1? 2.What was done at that time? 3.Were U hospitalized? 4.Was there serious consequences? 5.Are you under reg F/U? 6.When was the last time you saw your Dr? Li 1.Which medications are you on besides Li? 2.How much Li? 3.Is it measure d on a regular basis?

4.What was the level? 5.Any new meds/ or increase in dose? 6.How do you feel about taking Li? Any SE

Have U got TSH measured? When was the last time it was measured? Do you feel cold? Inc wt/Dec conc? Drink more/Pee more? Any urine analysis? Screen for Ataxia:Any shakiness/falls/difficulty in balance? Nx/Vx/Abd pain? If TSh Inc ct with Thyroxine If Di early Stop later Ct with Thaizude GI Stop Tremor B Blocker

Have you ever discontinued Li in past few yrs? TRANSITON: I know you’ve been asked this qn before, but I need to ask these qns PSYCHOSIS ANXIETY Past MH

Fhx of depression/Suicide/BP1 How do u support urself financially? COUNSELLING:

Compare between Mania & Depression What is your understanding about Mania? Mania is a condt that affects mood,in which people feel elevated it is one of the mood disorders it is common. Most people have depression, where people feel low & lose interest & Rx is often Talk therapy & medications. The Rx for Mania is lifelong,similar to DM,in which we can control Sx,but not cure it.There is a lot of research going on & ne day we hope to find a cure for it. If you choose to discontinue it,your chances of relapse are high upto 60% Coming to Li levels if 1.2 upper level of (N) & we can decrease the dosea bit & see how it affects you. But you’ve to PROMISE me that at any time you spend more,sleep less etc contact me or go to ER ASAP. Pt may accept .

When it comes to writing Thought block is not one of the SE of Li,give it time ,& see if it improves If S/o depression it is the other component of BP1 & I will refer you to psy. Therapeutic Tips

•A key feature of bipolar disorder is recurrent nonadherence to medication; including the patient in decision-making, together with psychoeducation, promotes a strong therapeutic alliance and enhances medication adherence. •Patients taking lithium need to maintain their usual salt and caffeine intake and monitor fluid intake and output, making adjustments in the event of unexpected losses due to vomiting or diarrhea.

•During acute manic episodes, patients may exhibit increased tolerance to lithium. •Advise patients taking antipsychotics about antipsychotic-associated body temperature dysregulation and strategies to prevent heat stroke (e.g., hydration, sun protection).

•For lithium-associated cognitive impairment, check lithium level and thyroid function. Lowering the dose or using a slow-release formulation may improve cognitive function. •Patients who experience tremor while taking lithium may benefit from elimination of dietary caffeine, lithium dose reduction or addition of a beta-blocker such as propranolol or atenolol. •Patients who experience diarrhea while taking slow-release lithium preparations may fare better with immediate-release formulations,17 particularly the oral liquid citrate salt.18

21/2/2011

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Introduction to physical exam:



“... If it is after history taking. “Thank you for the information. Now I’ll do some physical exam...hopefully towards to the end we’ll reach a working plan...”

During the physical exam – talk aloud. Verbalize everything. Don’t fail to drape the patient. Doing after vitals and general inspection. Lack of empathy (Warm hands and stethoscope and try it on your arm). You warn the patient before the exam, but also before any manoeuvre. If there is painful area – don’t repeat it. If the patient having

34 physical exams, and 11 management stations



(ER):

Physical Exam: 1.CVS 1.1.Essential Htn for the last 30y, 65 yo for f/u 10m 1.2.35yo dgn recently with Htn, do focused physical exam (CVS) 5m 1.3.25yo recently HTN, relevant physical exam 5m 1.4.60yo, Pain in calf muscles – history and physical 1.5. 35yo palpitations, history and physical. 10m

1.6.30-40yo, Cardiac murmur. 5m. 1.7.70yo A surgery 3d ago doesn’t pass urine 4hours – 10m (do JVP and vitals) 1.8.50yo SOB, 3d ago had surgery, 5m focus physical exam (emboli) 1.9.Car accident 24 ago, SOB, P/E 5m (fracture, fat emboli)) 1.10.SOB for the last, surgery 3d ago, 10m 1.11.History of heart failure for the last 10y, 3d ago SOB, 10m physical exam 2.RS 2.1.Cough, for the last 3d, focused p/e 5m 2.2.Female Hx breast cancer, mastectomy, chemotherapy and radiation 5y ago, a week cough or SOB (Pulm. Fibrosis) 2.3.Coughing blood 1w, 67yo, history and p/e 10m 3.GI

3.1.Lower abdominal pain last 24hr, 22 yof, 5m focused p/e 3.2.35 yof, came to the ER abdom. Pain 2h, 3.3.22 yof Hx of Crohn, abdominal pain 24hr, 5m focused p/e 3.4.30 yom abdominal pain, 5m focused 3.5.61 yom Hx alcoholic patient vomits blood, 5m p/e 3.6.25yof, epistaxis, bruising in skin, hematologic exam (ITP) 4.Neuro

4.1.HIV positive, headache for the last week – do cranial nerve exam (wear gloves) 4.2.40 yo, Difficulty in vision, Hx and p/e 10m 4.3.Crooked face (Bells palsy) - hearing and than 7th nerve, 5m focused p/e 4.4.Weakness in the Rt. Or Lt. Hand – see the power, reflexes and tone, history and physical 10m 4.5.Diabetic foot – do physical exam, 5m (monofilament test – 10m exam) 4.6.Unconcious – do neurologic exam for , 5m 4.7.Shakeness in his Rt. Hand (Parkinson) – 5m 4.8.Back pain

5.M/S – all joints except elbow. 5.1.Neck (level of the lesion) 5.2.Shoulder pain 5.3.Hand 5.3.1.Laceration in the wrist 5.3.2.CTS

5.4.35 yom – Hip pain (gonorrhoea), otherwise 5.5.Knee – Osgood Schletter, Chondromalacia patella and osteoarthritis 5.6.AP cruciate ligament, 5.7.Ankle – counsel patient. There is no fracture or rupture of ligaments. 10m 5.8.Back pain 5.8.1.Acute (3d ago) 5.8.2.Acute superimposed on chronic (fracture on metastasis) 5.8.3.Chronic back pain (young – Ankylosing spondylitis, old – spinal stenosis or osteoarthritis)

Intro Vitals

GI (I, A, Per, PS-PD, ST), DRE, Pelvic exam for females RS (I, Pal, Per, Aus, ST) CVS (I, Pal, A, ST), PV exam and JVP in the neck MS (I, Pal (Temp, Tenderness, Crepitus), ROM, ST) one below and one above joint. Neuro (I and orientation, CN, U and LE, Coord., Cortical sensation) InsBulk/PulpTonePowerReflexesSensation SEADS (Swelling, Erythema, Atrophy, Deformity, Scars)

Vitals: BP, HR, Temp, RR (“Based on the vital patient is stable I am going to do...) If there are no vitals you will say “I am going to start my physical exam by measuring the vitals by taking BP, pulse, temp...) If there are only 3 out of the 4 parameters – “Before I proceed I’d like to know what is the temperature...”

Weight and height in pounds and inches. (5 feet is 150cm, 6 feet is 180, 5,6 is 165cm) General inspection: lying down comfortably, no signs of distress Specific inspection: SEADS for each joint (Is it OK for you to lower your gown... ) Neck – no scars, erythema, atrophy, + muscle contractions; Normal cervical and thoracic curvatures. Back – no SEADS. From side – normal cervical, thoracic and lumbar curvatures. Shoulders – both shoulders are symmetrical, clavicles deltoid and scapulae are in the same level and angle. Hand – SEADS + thenar and hypothenar muscles.

Hip – I’d like to have full exposure. Hip joints are deeply seated joints – I am looking for any obvious SEADS and gluteal folds on the same level, and mentioning the lumbar curvature.

Knee INSPECTION:

(Stand, walk and lie down). 1. Stands up:

By inspection 1.(B)knees are symmetrical 2.(B) knee jts are normally aligned 3.No genu varus or valgus. 2.ask him to WALK: & look for: 1.Gait 2.popliteal fossa.(no bulge in popliteal fossa) 3.LIES DOWN:– SEADS

(B) Quadriceps muscles are in the same bulk. Ankle – SEADS, no open fracture no bruises. The last thing in the ankle is the gait. Gait – do in every joint besides shoulder, arm and hand. TTC (Temp, Tenderness, Crepitus)

If the patella is the same temp as the rest of the knee – there is inflam. Both patellae are the same temp. And colder as the rest of the leg. Quadriceps, suprapatellar pouch, patella (press and swing) – there is no signs consistent with chondromalacia patella, along the ...press on the collateral ligament, press to the back, when bending the knee: Up, Down, and In. Crepitus – no crepitus. Effusion – Bulging sign and milky test.

Bend your knee all the way. Normal or limited flexion. Can you push against my hand and pull. ST – cruciate ligaments, medial/lateral, and anterior posterior. Medial and lateral collateral ligament – varus and valgus stress test. McMeri test for the meniscus. Examine the other knee, pulse (popliteal). Examine above and below the knee (just mention it).

Patrick’s test (sacroiliac joint) and Thomas’ test (fist in the lumbar region – in case of osteoarthritis they need to do flexion by increasing their lordosis and feel less pressure).

KNEE



Intro: Good afternoon Mr XXX as I understand you’ve a pain in your (R) knee for the next few minutes I will be examining you,& if you feel any pain please let me know. I will also be reporting my findings to the examiner. Is that Okay with you? Can I proceed? Can I get the vitals please?

On General examination:

Pt sitting comfortably in no obvious distress Mr xxxx Can you please stand up? Can you please hold up your gown? By inspection 1.(B)knees are symmetrical 2.(B) knee jts are normally aligned 3.No genu varus or valgus. Can you please WALK: & look for: 1.Gait 2.popliteal fossa.(no bulge in popliteal fossa) Thank you, Could you please turn around walk back & lie down, I’m going to drape you LIES DOWN:– O/Inspection: 1.SEADS

2.(B) quadriceps muscles are in the same bulk I’m Going to feel your knee PALPATION: TTC (Temp, Tenderness, Crepitus) 1.Both patellae are the same temp & colder as the rest of the knee. 2.(B) Knees are symmetrical & there is no increase in temperature 3.(B)Quadriceps are normal in bulk 4.Suprapatellar pouch (N)

5.Patella (press and swing) – there is no signs consistent with chondromalacia patella, 6.Go along patellar tendon & end on Tibial tuberosity 7.No tenderness of T Tuberosity 8.press on the Medial collateral ligament, 9.press on the lateral collateral ligament 10.press to the back, for pop[liteal fossa Bend the knee: Open joint fully 11.Up for Femoral condyles 12.Down for ,Tibial condyles

13.In for the lateral & medial meniscus Relax your knee,I’m going to move your knee & examine for crepitus EFFUSION: •Eliminate the suprapatellar pouch •Press on patella ------->Patellar tapping ------>Bounce = Fluid •No bounce on patellar tapping •Bulging sign •Milking Sign ROM; Can you please bend your knee all the way (N) flexion Full flexion & extension POWER: I need to examine the stability of the knee: 3 tests:

1.Medial & lateral collateral lig Varus & Valgus stress test 2.Cx ligament: Ap drawer test 3.Meniscus : Mcmurray test Examine other knee POpliteal pulse

Dorsalis pedis pulse I would like to examine one Jt below & one jt above Ankle joint & back

HIP JOINT



Intro: Vitals G/E: Would you please stand up? Do you need help? Turn to (L) side------ go to back Ask examiner: Can I have full exposure? Can you please Roll up shirt,I’m going to look at your hip INSPECTION

The hip is a deeply seated joint,however I’m looking for SEADS (B) hips are symmetrical (B) gluteal folds are same level Lumbar curvature Normal PALPATION: I’m going to feel your joint,plz inform me if you’ve pain: 1.SI jt (N) 2.Post superior Iliac spine (N) 3.Iliac crest (N) 4.Ant superior iliac spine (N) 5.Greater trochanter (N) Plz walk to the wall,do you need help? Gait (N) No limping Can you please turn & come back? When standing look for EXTENSION Trendelenbergh test Can you please lie down DRAPE

I would like to continue my inspection anteriorly SEADS PALPATION: 1.Along inguinal ligament 2.Head of Femur 3.Symphysis Pubis Examiner will say (N) (Inspection & palpation done) ROM

1.Extension done when standing 2.Bend knee to abdomen as much as you can (flexion) 3.Abduction & adduction 4.Passive & active length Discrepancy in true length Hip lesion

Patrick test Thomas test Sensory fn

Knee joint & Lumbar joint

  SHOULDER
 

Frozen shoulder – active and passive are limited.

Rotator cuff – four muscles.

•Complete tear (initiation of abduction is lost 1st 30 -60) swing the hand or tilting and doing flexion and abduction. Cannot initiate and has painful arm and dropping.(DROP ARM) •Partial tear or tendinitis or impingement with same presentation (u/s or MRI can help to differentiate between them). Painful arch – can move, but it may ease him to turn the hand in supination. The empty can test – his arms fall. •Anterior dislocation – apprehension test positive. For posterior dislocation – push the elbow backward. •Bicepts tendinitis – supination and flexion (Jargonson test). Flexing against resistance (Job’s test). •Infraspinatus and teres minor – external rotation against resistence. Internal rotation for subscapularis (lift-off test).

INTRO: Is it Ok to untie your gown & is it Okay to kep it in your lap? INSPECTION: 1.(B) shoulders are symmetrical

2.(B) Deltoids are symmetrical 3.(B) clavicles are at same angle 4.(B) Scapulae are at same level 5.No SEADS PALPATION: I’m going to feel your joint, 1.Temp (N) 2.I’m going to press your joint 3.Sternal notch NT 4.(B) Sterno clavicular joint NT 5.(B) Clavicles NT 6.Acromio clavicular jts NT I’m going to focus on (R) shoulder & then (L) shoulder Press on: 1.Acromian 2.Spine of scapula till medial aspect of scapula 3.Tip of scapula 4.Spinal process of neck 5.Insertion of Supraspinatous NT (Greater Tuberosity) 6.Glenohumeral joint NT Sulcus Sign _ve (Pull down on shoulder) CREPITUS Relax I’m going to move your shoulder & feel the movts MOVE TO NECK & examine neck To ENSURE that shoulder pain not related to neck pain

ROM:

Please put your gown back stand up & face me Would you mind copying me Full flexion & extension Push back (extension) Int rotation Cross arms--- Adduction Move to sides all the way up to the head------ Abduction Ct moving down. Hold below (No painful arc) No drop arm SPECIAL TESTS: POWER PULSE

Chronic back x 6m0



INTRO: VITALS G/E

Can you please stand up? CAN YOU PLZ UNTIE YOUR GOWN? INSPECTION: If Hx,:1st inspection of face 1.Eyes for rednes 2.Mouth for ulcers 3.Nails: No pitting/ulcers/or skin changes Look at back Curvature ---Side:Normal cervical,Thoracic & Lumbar curvatures Back: No Scoliosis SEADS

PALPATION:

Warm hands & tell Pt: I’m GOING TO FEEL YOUR BACK, tell me if you feel pain Feel temp

Press Spinous processes individually Identify C7 Iliac crest: L 4-5 Press; Para vertebral muscles SI Jts TIE THE GOWN BACK & Ask Pt to lie down DRAPE I’d like you to do some movts for me: ROM

1.Can you touch your toes with your fingers without bending knees? 2.Arch your back backwards without bending your knees 3. Can you slide your arm along your thigh as low as you can? 4. Can you cross your arms & rotate the shoulder (Fix the hip) “Because I noticed you have restricted ROM of movements in all directions I’ll do a test called Shubert test. I will draw some lines on your back which are washable Dimples of venus – sacroiliac joints for line A 10 cm above ----- Line B 5 cm below ------Line C

Try & touch toes without bending back the difference from line B it should be at least 15cm. Less than 15cm – it is restricted. The 5cm below is for control WALK to wall: Gait (N) No limping Stand against wall Occipital from wall test.(When there is Shubert test positive ) Stand On toes – S1, Stand on heels L5. Pitting changes in the nails, psoriatic changes. CAN You please lie down? DRAPE SLR

Patrick test Listen to his heart for Aortic Insuff. Chest expansion – measurement in max inspiration and expiration (changes should be more than 5cm).

ACUTE BACK PAIN



Intro: Always ask Pt if he prefers to lie down or stand OCD: ONSET:

What were you doing at that time? Did you lift heavier than usual? Did you hear a snapping sound? Did you have to stop what you were doing? C PQRST: R: Does it move to the leg?,reach toe or thigh? Which bothers you more,The Leg or Back? EMPATHY........... Did you try any pain killer? A &A:

Lying down? Stretching? Bend/Move? U: V; ASx: 1.Weakness 2.Numbness 3.Tingling 4.Loss of balance & falls 5.Do you need to drag your foot? 6.How about Urine & Bowel symptoms: Some patients with similar condition may soil underwear 7.Numbness in buttock area? 8.H/O trauma to back?

9.Urinary: Dysuria/Flsnk pain? SOCIAL Hx:

Smoke Alcohol Drugs: ......Particularly IV drug use PE: G/E:

Vitals please

Can you please turn to side (so examiner can see) Can you please untie your gown? Dorso lumbar spine looks (N) curvature From Back: No scoliosis SI Joints appear (N) Tie gown ROM:

Forward flexion & extension WALK to bed & wall (Make sure that Pt does not FALL!!) Walk on heels & toes (support Pt) I’m going to raise your leg, please lie down & if it causes pain please let me know Can you please lie down? SLR SENSORY:

Start with Little toe:S1 1st Web:L5 (common peroneal nerve) Medial malleolus:L4 Knee:L3 Mid thigh:L2 REFLEXES: Knee Ankle Clonus

Babinski DRE Femoral stretch test End with Dorsalis pedis PULSES

Red Flag” Symptoms/Signs in Assessment of Low Back Pain

Condition Symptoms/Signs Investigations Herniated Nucleus Pulposus Positive SLR (leg pain at < 60°); MRI of lumbar spine weak dorsiflexion of ankle (L4-5) or great toe (L5-S1 or L4-5); reduced ankle reflex (L5-S1); reduced light touch in L4, L5 or S1 dermatomes of foot/leg1

Cancer Age > 50; previous cancer history; Positive laboratory tests unexplained weight loss; failure to (including elevated ESR, improve after 1 mo therapy2 reduced hematocrit) 2 and imaging showing erosion or blastic lesions

Spinal Osteomyelitis Intravenous drug abuse; sources of Positive laboratory tests infection (e.g., skin, teeth, urinary and imaging tract, or indwelling catheter); fever; vertebral tenderness3 Spinal

Fracture/Compression Fracture Age > 50, female gender, major Positive laboratory tests trauma, pain and tenderness, and a including plain x-rays distracting painful injury;4 also consider a history of osteoporosis or corticosteroid use Cauda Equina Syndrome

Acute urinary retention or overflow Emergency laboratory incontinence; loss of anal sphincter assessment and imaging tone/fecal incontinence; perineal numbness; change in sexual function; weakness of legs1

Factors Adversely Affecting Prognosis of Low Back Pain Psychosocial Factors Mental Status Indicators of Significant Anxiety or Depression

1.Duration of work absence 2.High levels of self-reported functional disability 3.Self-report of extreme pain and constant pain in multiple body areas 4.History of prolonged sick-listing after previous injuries 5.Prior history of absenteeism 6.Delays/obstacles in work re-entry process 7.Patients who believe that they will never return to work 8.Adversarial attitude toward employer 9.Long-standing history of psychiatric distress or maladjustment

1.Insomnia or nightmares 2.Irritability

3.Withdrawal 4.Panic episodes or anxiety during the day or night 5.Persistent tearfulness 6.Poor concentration 7.Inability to enjoy (anhedonia) 8.Poor appetite/weight loss 9.Poor libido 10.Thoughts that ―life is not worth living‖

NECK EXAM



INTRO: Vitals Pt stable G/E: INSPECTION: I’d like to take a look at your back, can you please untie your gown? (N) Cxal curvature---- Look from side look from back

SEADS PALPATION: I’m going to feel

1.(N) Temp 2.Press along individual spinous proceses (C1 to C7) 3.P Vertebral muscles 4.Trapezius 5.Sternocleido mastoids 6.Mastoid process 7.LN

8.Thyroid (ask the patient to swallow) ROM: I’m going to examine ROM Copy me, 1.Touch chest to chin-----> Flexion 2.Look at ceiling -------> Extension 3.Turn to R/L Rotation 4.Touch shoulder to ear ---- R & L Lateral flexion 5.Check Streno Cleido mastoid by pressing against my hand & push to back (? Not done!) 6.Neck pain not associated with muscle spasm 7.Can you cough? ------ “No neck pain with Valsava’s manoeuvre” Part of my exam is to check your UppExt: Can you roll up your sleeves? INSPECTION:

1.(B) U extremities are symmetrical 2.No abnormal posture or contracture 3.Bulk is symmetrical PALPATION: See & feel deltoids, biceps, Triceps, forearm, Thenar & hypothenar muscles TONE: WRIST:

No cogwheel rigidity Elbow

No Pb pipe No clasp knife rigidity SENSORY: C6 C7 C8 C4 ------ REFLEXES POWER: In U/E Deltoid Biceps

Fan fingers Power of thumb SPECIAL TEST: Spurling test Ask Pt to stand: Check Clonus & gait CNErve exam

  HAND Laceration

Hx: 1.AMPLE + Tetanus 2.Mood 3.Handedness (occupation : can affect if Pianist, Speech therapist, Plastic surgeon) 4. X ray

5.5. 6.Irrigate with NS 7.Antibiotic prophylaxis 8.NPO INTRO:: As pt has an injury,I would like to get gloves for protection Greet Pt & ask for vitals G/E;

Remove bandage & describe the wound: Position: wound on palmar aspect: 3 cm in length/2mm width/depth cannot be assessed 5-10 cm proximal to wrist on Volar aspect No active bleeding/No oozing/Margins clear & not elevated (B) hands are symmetrical SEADS Colour similar I’m going to FEEL: Temp (B) hands is normal (N) Capillary refill

I’m going to feel your hands to see if there is damage to the arteries (N) radial artery & ulnar SENSATIONS: Lt touch Ulnar/Median/Radius Tenderness to PALPATION: Distal radius/Styloid process/distal part of ulna & styloid process/base of thumb Press carpal bones & metacarpal bones ROM: try to do on table & not move elbow Ulnar deviation

Radial deviation MPOTOR FN OF MEDIAN N: OK Sign Ulnar N :Able to hold peice of paper betn Adducted finger & resist pulling RADIAL N: Extend thumb Thumbs up THUMB: Make a fist & fan out fingers Can you touch ........your thumb to the tip of your little finger? (flexion) Take it all the way to other side ? (extension) Point to ceiling (Abduction)

Put close to your hand?(Adduction) Touch thumb to tips of fingers? (opposition) FLEXION: Can you bend your fingers one by one?----- Flexor digitorum profondus Flexor Doigitorum superficilias

CTS



Pain in (R) wristy x 2 wks: Hx & PE OCD PRTY UV A&A ASx CSx D/d: 1.CTS 2.Spinal stenosis/OA/Cervical disc herniation 3.TIA 4.Thoracic outlet syndrome OCD: O: C:

How often? Daily? Since when daily? Before that? At Night? D: How long each attack? What brings these attacks?

What relieves it? What do you do for a living? PQRST:

P: Can you show me where it is? Q; S: U; V: A & A:

Movts/Medications/Repeated movts Local Sx: Swelling/Numbness/Weakness/Other hand/Leg/Bladder & bowel disturbances CSx: AETIO: I’ve to ask you qns as to the presence of any condt that might have caused this: 1.Hx & Sx of DM: 2.Hx & Sx of Hypothyroid 3.Hx & Sx of Acromegaly

4.Trauma 5.Fall 6.HX of RA D/d: Neck pain Past MH: HTN/any long term disease Social Hx;SAD Fhx: Thank You for this information,I will now proceed to the PE GE: INSPECTION: 1.(B) hands are symmetrical 2.No SEADS

3.No Bouchardfs nodes 4.No Swan neck deformity 5.(B) Thenar & Hypothenar muscles equal bulk FEEL: 1.Temp & capillary refill 2.Palpate distal part of radius of hand 3.Bulk of thenar & hypothenar muscles ROM of wrist THUMB: Power check against resistance,pu;ll up & down & pull Hook thumb ….. BICEPS: Check Power & Reflex NECK: ROM to R/o C6 SENSORY: 1.Little finger :Ulnar

2.Ring Finger:Ulnar aspect for Ulnar nerve & radialaspect to R/o median nerve 3.2 POINT DISCRIMINATION: Only in Index finger SPECIAL TESTS: 1.Tinel’s Tap at medial aspect of wrist x3 times Ask if feels numb 2.Phalen’s sign PULSE: Radial T

TREMORS

PARKINSONISM

INTRO: Vitals: G/E:

Pt is sitting There is an obvious tremor in (R) hand (N) elbow

No tremor in shoulder

Ask patient to count from10 to 1 backwards: & observe the tremor.... •Tremor does not disappear on mental activity but increases, which is consistent with Parkinsonism, & R/O Anxiety related tremor Please extend arms & fingers: •No fine tremors R/O Thyroid disease •No flapping tremors R/O Liver disease •Can you touch Finger to my finger & then to your nose? No intention tremor R/O Cerebellar disease

There is no dysdiadokinesia Pt has a limited facial expression Limited eye blinking No drooling

INSPECTION:

Tremors in (R) hand, which are pill rolling & involve the (R) arm Pt does not have tremors in (L) hand, arm & shoulder NO head nodding I want to examine the TONE: •Cog wheel

•Pb pipe •Clasp knife Ask pt to please stand There is difficulty in initiating movt Stooped posture Decreased arm span Festinant gait Turns in block Ask Pt to say: British Constitution (N) articulation

Ask Pt to write; Micrographia I want to check for orthostatic hypotension Difficulty in rapid alternating movts: 1. 2. 3. I would like to arrange for a MMSE which can happen later.

 

HIV Pt with HA/PE (Cranial nerve exam)



1st nerve. (Coffee and ammonia). I’m going to skip the first nerve. I’ll ask the patient if he has any difficulty smelling. 2nd nerve.: OPTIC NERVE (5 tests):

ACUITY:

Ask Pt for best vision or if he wears EYE GLASSES

Hold Snellen’s chart with (R) hand & cover Lt. eye. Choose a mid-line, jump two lines below, and finally last line. COLOUR VISION:, then the other eye, change eyes, ask colour first in a reversed order and if he sees in the same intensity. Go straight to last line and ask to read backwards. VISUAL FIELDS:

(DDx one eye blindness, bitemporal and homonymous hemianopia) PUPILLARY REACTION: I am going to shine the light in your eyes it might might bother you: first shine at the (R) Look at the (R). Eye, second shine in rt. Look at left side, 2 shine light in eyes & see pupillary reaction : 2-3nerve (2- afferent, 3-efferent) FUNDOSCOPY:

verbalize (DM: microaneurysms, cotton wool spots, neovascularisation; Htn: flame hemorrhage, disc edema, nipping of veins)

3rd, 4th and 6th

I am going to examine the nerves which cause movement of the eyes. INSPECTION:

(B) eyes are symmetrical, No deviation. No head tilting (4th nerve), No ptosis (3rd nerve), No nystagmus.

Tell patient to look at the tip of pen and follow with eyes and when you see double vision please tell me.

Start from middle and create an H. Then go to centre and check conversion. “Normal extraoccular vision, no limitation, no nystagmus.” 5th nerve: motor and then sensory. INSPECTION:

No atrophy in temporal and masseter area. I am going to examineSENSORY:. This is a piece of cotton, I’ll put in on your chest – this is how it feels. Now I am going to touch different parts in your face while your eyes are closed. Whenever you feel it touches you tell me. Then ask him if it is the same feeling. MOTOR: clench teeth and relax twice. Feel the bulk of the temporal and masseter – they should be similar bulk. Can you push your jaw against my hand? 7th is mostly motor. Sensory for the tongue (anterior 2/3). Corneal reflex efferent limb.

INSPECTION: Face symmetrical, Normal nasoliable fold, No drooling,

No deviation of angle of mouth. Now copy me: raise your eyebrows, frown, close your eyes and don’t let me open them, puff cheeks and don’t let me blow out, show your teeth, and whistle. I would like to check corneal reflex in the eye 8th nerve.

I am going to whisper words in your ear. Repeat after me (“horse” and “house”). 9th and 10th

1.Normal voice, no hoarseness.

2.Swallow for me – swallowing is normal. 3.Say AHAA – soft palate symmetrical, uvula is central. 4.Gag reflex I’d like to do.

11th nerve – shrug your shoulders (“Normal trapezius”). Turn your head to the right against resistant and feel the bulk of the sternocleidomastoid.

12th nerve – no atrophy/ fasciculation of the tongue no deviation of the tongue. Wiggle your tongue left and right.

Unconcious Patient



INTRO: Hello, Mr….DO you hear me. If you hear me open your eyes. I am Dr. … one the physicians working in the clinic. FIRST CHECK PUPILS:

Pupillary reaction – pupils are round and symmetrical and reactive. Not dilated or constricted. There is no pupillary discrepancy. If one is reacting & the other not reacting – call neuro. If you hear me – can you move your eyes up and down? “There is no locked-in syndrome”. Vitals (Cushing triad absent; If the patient has fever we will verbalize it). GCS Cranial nerve:

1.2-fundoscopy, 2.2-3 – pupillary reflexion, 3.3-4-6 – eye deviation, 4.5-7 – corneal reflex, 5.7 – inspection of face symmetry, 6.9-10 – gag reflex Upper extremity:

Inspection (symmetrical, normal position, no movement, no contractures), tone, reflexes (biceps, triceps, brachioradialis) Lower extremity:

Inspection (symmetrical, normal position, no movement, no contractures), tone, reflexes (knee, ankle, Babinski) Meningeal signs

Neck stiffness, Kernigs, Brudinsky Babinsky Special test: Caloric test, Dolls eyes



ER



Trauma Non-trauma Hx + Transition A B C

D AMPLE

Head to Toe Orders ABCD History of present illness CC PQRST (Head to toe) ASx Α PMHx (Risk Fcts) Focused P/E Orders

In ER don’t be comfortable till after primary survey and IV lines. If non-trauma patient in ER – you do primary survey (shortened), more time on history and focus on CC.



Case of Trauma



I’d like to initiate ATLS protocol and I’d like protection to my team and myself (gown, goggles, mask, and gloves).

When walk to patient ask the nurse: How is the patient doing? What was done till now? If not wearing collar – tell nurse to fix the head, tell patient not to move “we need to fix your neck collar for your neck”.

Take a small history: “how do you feel right now?” (to see if he can talk). If complains of severe pain (empathy: I can see you are in pain, please bear me with me for a few minutes, as soon as I can I will give you a pain killer. At the moment I want to make sure you are stable for that reason, I am going to give some orders to the nurse, and as soon as I am done I’ll ask you more questions).

A - Airway

Please open your mouth. Mouth clear, the Flip your tongue: “there are no clots, foreign bodies, broken teeth, and Patient is talking to me – that mean airways are patent.

B Can I get the saturation?”

Give oxygen. If saturation is 95% than you give oxygen – ask if the saturation improved. Oxygen + saturation is a part of B.

Open the neck collar and look for trachea deviation, Jugular vein. Trachea J Veins Air Entry Heart Sounds Normal Central - Bilateral S1, S2

Tension Pneum. Opposite side Increased Decreased same side S1, S2 Hemothorax Opposite side Low/Normal Decreased same side S1, S2 Cardiac

Tamponade Central Increase Bilateral Muffled Pneumothorax – large bore needle in 2nd intercostals, midclavicular line, upper margin of the third rib.

Hemothorax – insert chest tube in 5th intercostals space mid-axillary line. Ask nurse “how much blood” (If > 1.5litre – ask for thoracic surgeon, also if greater than 800cc in 4 hours). If less – monitor.

Cardiac tamponade – ask for thoracic surgeon. Pericardiocentesis – needle in mid-xyphoid 45 degrees towards the tip of the scapula and look for blood. Continuous ECG. C

Vitals (every 10 minutes), and blood orders. “I’d like to get the vitals.

Comment if hypotensive tachycardia. I’d like to start 2 IV lines 16G in both anti-cubital fossa. 2 litre bolus Ringer lactate in one side, and from the other take blood. If no improvement after 2 litres – give another bolus. If deterioration in vitals – give blood. Finger prick glucose; BLOOD for: •CBC, Lytes, Group, Cross match, • INR, PTT, LFT, BUN, Cr, •Toxoc screen, Alcohol level.

If unable to get the IV line – insert intraosseous line (IO). •Order 6 units of blood: 2 O positive for male or negative for female in reproductive age and add 4 units of cross matched blood (pRBC). •Continuous ECG±cardiac enzymes (troponine, cpk-mb), Ask the change in vitals again & results of blood glucose.

Ask if 2litres were given. If stable – OK. If UNSTABLE:– look for source of bleeding. Start with ABDOMEN:

INSPECTION: listen, and palpation. If bruising – ask for surgical consult stat. If not available ask for FAST. If technician is not available – then DPL (Diagnostic Peritoneal Lavage). Then go for the

PELVIS:– I am going to press on hips to see if there is any pain. If complain of pain tell “I suspect pelvic fracture” Wrap sheet and call ortho stat. Look at the LOWER EXTREMITY: No internal/external rotation, feel there is any pain, difference in the legs. If you suspect fracture ask for Thomas splint and check the pulse before and after. Log roll – check for spinal process and DRE.

D D1- Deficit – Gross Neurological:

Shine light to both eyes “Both pupils normal size reacting to light. Can you squeeze my finger, wiggle your toes. Touch his sides of both upper and lower limbs – can you feel my touch. “Patient is grossly neurologically intact.” If unconscious – check papillary reaction and assess GCS. D2 – universal antidote Thiamine, Glucose,& Naloxone. D3 – specific antidote.

AMPLE Allergy Medication

PMHx Last meal, Last tetanus shot, LMP (if female) Event – describe the event (Rear end, T bone, Head on); Were you driver/passenger/alone? Have you had any head trauma? Do you remember anything before or after the event? Do you have nausea/vomiting/headache. Head-Toe examination

Orders

Hypertension/Secondary



As I understand you came here today because you were diagnosed with increased blood pressure. I’ll do a physical exam on you. Can I get the VITALS:please?

1.Patient have (B)systolic & diastolic blood pressure raised. 2.Patient does not have tachycardia, r/o pheochromocytoma and thyrotoxicosis. 3.Patient does not have bradycardia – r/o hypothyroidism. 4.I’d like to compare BP in upper and lower extremity to r/o coarctation of aorta. 5.I’d like to r/o orthostatic hypotension for pheochromocytoma. 6.Check orientation: Time, Place, and Person On general examination: Patient sitting comfortably •No sign of truncal obesity • No cervical fat pad. •Face is symmetrical

•No moon like face

EYES:

•Normal eye brow, •No puffiness around the eyes •No exophthalmus, •Please Follow my finger – there is no lid-lag or lid retraction. •Sclera for anemia or pallor. •No xanthelasma or arcus senilis • On fundoscopy there are no signs of Htn.

•No loss of visual fields (acromegally). NOSE:

•Nose OK (septal perforation in cocaine abuse).

HANDS:

•Symmetrical, •skin normal not dry or moist, no sign of drug abuse (needle puncture). •Normal capillary refill, •No clubbing •No nicotine staining. •Please stretch your hands – no fine tremor. •Pulse – regular, normal volume and contour. •Compare both pulses. (When lies down – take radio-femoral delay.) • Abduct shoulders to check proximal weakness for Cushings.

NECK:

•feel thyroid, swallow, •ask patient to lie down, put bed at 45 degrees and ask for JVP. • Check for carotid bruit (first listen than palpate)

BACK:

•Listen between scapula for collateral circulation and bruit (COA) • Base of lungs for creps and heart failure. •Press on sacrum and ankle for edema. CHEST: (lies down, please lower your gown) • chest is symmetrical. •No obvious pulsation. •I am going to feel. •Feel for apex beat, fine and identified PMI position and size, not enlarged not displaced, not sustained.

•No parasternal heave. •Listen to mitral area – normal S1, S2 •Move to bell and lie on side: no S3 and S4 ABDOMEN: •abdomen non-distended, symmetrical, no pulsation, no striae, no caffe au lait, no obvious masses.

•I am going to listen to the abdomen. 2 inches above umbilicus is the aortic bruit, renal is 2 inches on the same level, and the iliac are 2 inches below on 45 degree below. •Tap, feel dullness in renal area for masses. No supra-renal masses. • Femoral-radial delay, •No peripheral edema. Neuro: Kneel on chair and do ankle reflex a Quick neuro.

 

P/E of CVS



INTRO: VITALS: (Thank you for the Vitals)

Both Sys and Dia BP are elevated, HR is normal. Orientation: time, place, person G/ E:no obvious obesity HEAD: Eyes - ±pallor/arcus senalis, no xanthelasma Mouth: no dehydration FUNDOSCOPIC: exam

HAND:Temp/Capillary refill/Clubbing/Nicotine stain

Pulse: regular/normal volume and contour NECK: at 45o look for JVP, listen to carotids one by one, then palpate carotids CHEST: ask to lower gown INSPECTION: Sit and look for pulsation PALPATION: PMI Feel apex/thrills/heaves

AUSCULTATION: Aortic/tricuspid/MV, lay patient on left side, no S4 Sit up and lean forward, breathe out and hold it – listen if there is aortic regurgitation (?) Listen to base of lung Press on sacrum for edema. Ask patient to lie down on bed ABDOMEN: listen to bruit (aortic, renal and iliac) LOWER EXTREMITY: temp, capillary refill, dorsalis pedis and peripheral edema

Three places you look for orientation:

•Volume status •Malignant hypertension •Hypoxia and SOB

Volume Status



79 Hip replacement 3d ago, nurse asked to come and see, not passed urine for four hours. Do Volume status exam. INTRO:

VITALS: (and mention that BP should be done twice – while lying and sitting) After measuring BP in one position, there are two minutes before you measure the second position, meanwhile you do (the cuff of the BP should be on the same level of the heart). Width of cuff is equal to 40% of circumference of arm. 1.ORIENTATION:Time, Place, and Person. 2.Listen to the base of the lung. 3.Look for sacral edema.

4.Look for sclera for pallor. 5.Mouth: open and look for dehydration. Flip tongue for central cyanosis. 6.Look for hands, skin (moist and dry). 7.Capillary refill – should be less than 2s. Measure HR again and BP. If there is no increase in pulse more than 20bpm and no decrease in SBP more than 20 or DBP more than 10 – there is no orthostatic hypotension. If one of them is positive – Orthostatic hypotension.

Put patient at 45o to do JVP. Press on base to see if JV disappears. Measure. Take deep breath and hold – Kussmaul Sign absent. Untie the shirt and do hepato-jugular reflex. INSPECTION – S3 and S4 and all cardiac exam. ABDOMEN: percussion at suprapubic to see if bladder is full.

Pedal edema, than look at examiner and ask for: input-output chart & weight charts. (If there is cathter:) I’d like to make sure that the catheter is not kinking. Back to Content PVD

Pain in calf for three months. Vitals (“patient is stable”), if patient is wearing socks ask him to remove them. INSPECTION: (B) Feet: SEADS+3: •Normal hair distribution • Skin non-tight and shiny •No hypertrophy of nails

PALPATION: (I will feel your feet): •Peripheral temperature •Capillary refill

•Pulse (both sides): DP, PT, Pop. & Femoral. Drape the patient and listen to his abdomen for bruits. Feet – LIGHT TOUCH SENSATION: Bergers test – raise legs for two minutes – any you feel tingling/numbness tell me. After two minutes tell: “no pallor, pain, numbness, tingling.” Sit up and dangle his feet – “No rubour on depandance.” I would like to do ANKLE BRACHIAL INDEX

Diabetic Foot



Intro (As I understand you are here today cause you have DM for 2 y and ulcers in your Rt leg. I have to do a P/E) Vitals – stable. Drape and remove socks. INSPECTION:

Look at sole of foot. Ulcer – 3cm in diameter, round, margin not elevated, no active bleeding or oozing, located at base of 1st metatarsal. I am going to look for other ulcers at the base of the toes (Between medial and lateral maleolus.) Check SEADS + 3. PALPATION: Temp and capillary refill.

Shift to NEUROLOGICAL EXAMINATION: LIGHT TOUCH SENSATION in glove and stocking manner. Start with big toe and go to level – and than up and down until finding the right level. Light touch absent or decreased at a level to distal point. For example – above wrist. And then say to the patient: “Thank you and open eyes.” POSITION SENSE: close eyes and move the big toe up and down five to six times. “Thank you. Open your eyes.”

VIBRATION SENSE: tuning fork – put on sternum to show how it feels, then put it on the 1st interphalangeal joint. If doesn’t feel – vibration sense absent. Start with first joint, and second joint (you check vibration also for (1) medial maleolus, (2) tibial tuberosity, anterior superior iliac spine, sternum, chin, and forhead). (1) and (2) are for spinal injury. ANKLE REFLEX:

MONOFILAMENT TEST: press on sole or foot. Feel or no-feel. Increase the pressure & bend the monofilament. “He has lost light touch and pressure.” But if feels when pressure, say: “pressure present but light touch gone.” You check the same way in 9 points on the sole.

PULSES: DP, TP Auscultation (?) and ABI (Ankle-Brachial Index) Acute Abdomen, Physical exam

Intro

General inspection: the patient is lying comfortably and I see no signs of distress. Can I get the vitals please?

The patient is stable, normal temperature, BP and HR. You are going to face – can I take a look at your eyes: there is no jaundice, no sign of anemia. Please open your mouth – there is no sign of dehydration and obvious ulcer in the mouth. Upper extremity: capillary refill is normal.

Abdomen (drape appropriately): please move the cover – by inspection: the abdomen is not distended, umbilical inverted, abdominal moves with breathing, no scars, no bruises. Ask patient to look aside and cough twice (once look at his face to see for cough tenderness and then for abdominal bulging).

Now I am going to listen (warm the sthetoscope): “Normal bowel sounds, no bruits – aorta, renal, and iliac.”

Percussion: I am going to tap – show me where it pains. First tap away from painful area, than tap over the 9 areas – the painful area last. Pulpation: I am going to feel – no tender in epigastric/Rt. And Lt. Hypochondral/Rt. And Lt. Iliac regions/ Umbilical / Suprapubic. Deep pulpation: I am going to apply more pressure – there is no guarding in deep pulpation, there are no obvious masses. Now I am going to feel your kidneys – there is no enlargement of your kidneys. Now I am going to do some special tests.

Murphy sign Rebound tenderness. McBurny sign. Rovsing sign.

Psoas sign. Obturator sign.

“Please sit up. Now I am going to tap your back. There is no tenderness on costo-vertebral angle. Now listening again to the base of the lungs. There is no crepitus at the base of the lungs.”

“I’d like to finish my exam by doing pelvic exam, vaginal exam for bleeding or discharge or bimanual examinations. Looking for any cervical motion tenderness, and adnexal masses.” “In DRE looking for any bleeding or haemorrhoids.”

Acute on chronic abdomen (like Crohn’s Dis.) Add to the above:

General inspection: moon faces, truncal obesity, redness in sclera, nails – pitting and clubbing, no skin rushes, no striae, no erythema nodosum on legs, sacroiliac joints look normal.

 

Acute Abdomen, Physical exam



Intro General inspection: the patient is lying comfortably and I see no signs of distress. Can I get the vitals please?

The patient is stable, normal temperature, BP, RR and HR. You are going to face – can I take a look at your eyes: there is no jaundice, no sign of anemia. Please open your mouth – there is no sign of dehydration and obvious ulcer in the mouth. Upper extremity: capillary refill is normal.

Abdomen (drape appropriately): please move the cover – by inspection: the abdomen is not distended, umbilical inverted, abdominal moves with breathing, no scars, no bruises. Ask patient to look aside and cough twice (once look at his face to see for cough tenderness and then for abdominal bulging). Now I am going to listen (warm the sthetoscope): “Normal bowel sounds, no bruits – aorta, renal, and iliac.”

Percussion: I am going to tap – show me where it pains. First tap away from painful area, than tap over the 9 areas – the painful area last. Pulpation: I am going to feel – no tender in epigastric/Rt. And Lt. Hypochondral/Rt. And Lt. Iliac regions/ Umbilical / Suprapubic. Deep palpation: I am going to apply more pressure – there is no guarding in deep palpation, there are no obvious masses. Now I am going to feel your kidneys – there is no enlargement of your kidneys. Now I am going to do some special tests.

Murphy sign Rebound tenderness. McBurny sign. Rovsing sign. Psoas sign.

Obturator sign. “Please sit up. Now I am going to tap your back. There is no tenderness on costo-vertebral angle. Now listening again to the base of the lungs. There is no crepitus at the base of the lungs.”

“I’d like to finish my exam by doing pelvic exam, vaginal exam for bleeding or discharge or bimanual examinations. Looking for any cervical motion tenderness, and adnexal masses.” “In DRE looking for any bleeding or haemorrhoids.”

Acute on chronic abdomen (like Crohn’s Dis.) Add to the above:

General inspection: moon faces, truncal obesity, redness in sclera, nails – pitting and clubbing, no skin rushes, no striae, no erythema nodosum on legs, sacroiliac joints look normal. Back to Content Hematemesis “Because it is hematemesis I’d like to initiate a ATLS protocol for me and my team, please can I can get gloves, goggles, masks, and gowns.” Intro How do you feel right now? I want to make sure you are stable and therefore I’ll give some orders to the nurse. Once you are stable I’ll ask you some questions.

ABCD

Vitals OCD + COCA How did it start? Forceful and retching? Did you vomit once or more? How much? Dark /bright blood?

Any clots? Any smell? IMPACT±PAIN -PAIN  Liver

+PAIN  GIT If No Pain: Hx: Any Hx of liver disease? Any screening for liver disease? Any bruising in body? Increase in abdominal size lately?

Alcohol: how long? How much? Hx of PUD Heartburn Any nausea When was your last bowel movement? Colour? Any tarry stool/fresh blood? Any Hx of bleeding disorder? Any NSAIDs (Aspirin) – how much? How long? Why? Who prescribed? Any blood thinner? CSx (Ask for weight loss)

Long term disease Physical exam:

Vitals If suspected liver disease (no pain): Sclera – no yellow discoloration, pallor Enlargement of parotid glands

Mouth: Fetor hepaticus, mouth is clear no bleeding no clots Hands: no clubbing, capillary refill, no atrophy of thenar or hypothenar, no palmar erythema, no dupytren’s contraction, no flapping tremor Chest: no spider nevi, no gynecomastia, normal chest hair, no bruising Abdomen: not distanded, umbilicus normal, caput medusa, collateral veins, no bruising. Auscultation: bowel sounds normal, bruits (aorta, renal, iliac), no hepatic rub, hum, or bruit; No splenic rub, hum Tapping: four taps – general percussion, percussion for liver (upper and lower margin), spleen (Castle sign), shifting dullness DRE Testicular atrophy Peripheral edema Epigastric tenderness

Gastroenterologist consult and admit to ICU Endoscopy and IV PPI

Acute Abdomen – management



Abdominal pain 24 hr with vomiting and diarrhea, BP 90/60, Pulse 140 Diagnosis: acute pancreatitis

Intro: “As I understand... please bear with me, as your BP is low I’ll give orders to the nurse, and as soon as you become stable, I’ll give you something to relieve your pain.” A B– Vitals, Oxygen saturation C– because he is hypotensive and tachycardic you give IV fluids; Take blood to: (add amylase to the other blood work) D– Gross neurological exam Hx What happened?

Pain: OCD, PQRST, AA Vomiting: how much, how many times, amount, forceful, blood/coffee ground IMPACT RF (Alcohol, Gall stones, Hypertriglyceridemia, DM, Viral infection, Medications) Recent trauma Alcohol: how much, when was last time, last drink (was it more than normal?) Hx of gall bladder disease Recent flu DM Medications CSx

Hx of HTn (R/O Aortic dissection) Chest pain Cough, phlegm Flank pain Liver disease PMHx FHx SHx

Vitals 2min stabilize, 4min Hx

P/E Look for liver disease: sclera, tongue, and hands Abdomen: Drape No Cullens and Great Turner signs. Look for cough tenderness. Auscultate bowel sounds: no aortic/renal bruit. Feel or tap abdomen Groing exam DRE Orders: Meperidine, NPO, NG Tube, Admit to ICU, Foley catheter, Input-output chart, Imaging: AXR, Abdominal U/S and CT, surgical consult  

MI – Management



Hx OCD

PQRST (if it is suspected to be ACS - stop at R and start primary survey) Primary Survey (If patient talks – Airway preserved, Take Oxygen saturation and start Oxygen Stat – 4L/m through nasal prongs) VITALS: Auscultation: •Air entry (N) •S1 & S2 (N)

IV lines : NaCl 50ml/hr to keep line open, from the other side take blood for: Troponin, CK-MB, Cr, BUN, Lytes, CBC, INR, PTT, LFT, Toxic.,

Alcohol, Lipids; and finger prick for Glucose) ECG 12 leads & continous monitoring Portable X-ray (r/o dissection)

Ask about Allergy for Aspirin and Viagra (if negative)[12hrs for Viagra & 36 hrs for Cialis] Give ASA chewable (325mg) Non-ST elevation

Nitro x3 (S.L) Morphine Continue now with: PQRST AA&A How do you feel now? Ask Hx: CVS GI (especially peptic ulcer) CSx

RS DVT ST Elevation: do not go for DDx Nitro (IV Nitro is C/I in IWMI) Morphine (5mg if ALMI, and 1mg if PWMI) VITALS: (again)

R/O Contra Indications for Thrombolytics: •Peptic ulcer & Recent surgery, •Pericarditis, Aortic dissection, •Brain tumor, & Stroke Start Thrombolytics:

Tpa

•Ask for heparin protocol •Start B Blocker RISK FACTORS: • HTN •DM •FH

•Coccaine Nitro (2nd dose) O/E: •JVP •Listen to heart •Base of lung

•Compare BP in both Upper extremities to r/o coarctation of Ao CXR Once there is no Aortic Dissection  Thrombolytics (should be clear to r/o: Peptic ulcer, recent surgery, pericarditis, aortic dissection, brain tumor, and stroke) Based on ECG – counselling

Counseling

Based on your ECG it is most likely you are having an heart attack. If stable – BP and HR are stable, but it is a serious condition, however it is treatable. Heart attack means that greater than one blood vessel supporting your heart is blocked by a clot that has to be reimoved. The medications are called clot busters. Based on ECG and no sign of pericarditis or signs of aortic dissection you are a good candidate for treatment. It is an effective medication, needs consent. 1% chance of stroke and we can start heparin.

Respiratory System – P/E



•General inspection: comfort, colour, pursed lips, flare nose, intercostal retractions, auxiliary muscles

•Eyes, nose (perforated septum), mouth (ulcers, thrush in HIV, central cyanosis, moist tongue) •Hands: peripheral cyanosis, clubbing, capillary refill •Cervix: trachea, lymph nodes •Chest: inspection (symmetry, expansion, intercostals retractions); Palpations for any pains, estimating chest expansion Tactile phremitus (“99”) Tappings (including sides): dullness/tympanic, diaphragmatic excursion Auscultation (including sides): vesicular sounds Vocal phremitus: “E” Whispering pectoriloqui: “1,2,3”

•Heart: pulses and auscultation (r/o AF and Rheumatic disease). •Other lymph nodes: axial, femoral, popliteal •Lower leg: no signs of Caposi sarcoma, DVT (Homan sign, measuring calf in case of tenderness or suspicious calf swelling).  

Diabetic Daughter 2y, Counsel



Either she is not doing well in school as she is not seeing well due to vision problems Not playing well, as she is tired DKA

Is it regular f/u or something special you wanted to discuss? When was the last f/u? How was she diagnosed?

What happen then? What were the symptoms? Any pain / vomiting? Are you feeling eating/drinking/peeing more? Any weight loss or blurred vision? From the last f/u till now have you had DKA?

How about before? Have you had low blood sugar? Talk with the father: Which medication does she take? How does she take?

When was the last time? Do you take insulin or somebody else gave it to you? Do you take it all the time? DO you skip dose? Does she need any help to take insulin? DO you measure blood sugar regularly? When was the last time?

Do you record them in the machine? (The glucometer should be used by only one patient). There is a blood work called ―Hemoglobin A1C‖ it is done every three month – did you do it? Did you start new medication?

How about your diet? DO you have your log book? What do you eat? Have you ever seen by a dietician? PMHx FHx

Counseling A lot of people have diabetes and she is not the only one. What’s your understanding of diabetes?

Whenever we eat food contains sugar it is absorbed in our stomach and goes to the blood and from there to different parts of our body. Sugar act in our body like a fuel, in order for our body to use this energy it needs insulin. Patients having diabetes have not enough insulin. Sugar will be built up in your blood. The body tries to get rid or it, by peeing extra sugar – this will lead to thirsty and tiredness.

This can be avoided by controlling the blood sugar. If you control your blood sugar you’ll be able to play again. If not controlled – may end in DKA, hypoglycaemia and serious consequences. Always be aware of hypoglycaemic symptoms: loss of conscious, sweating, heart racing, hungry. Since you might lose conscious it is important to carry MedAlert Caed or Bracelet which will clarify your situation.

  Medical Error, Wrong blood transfused



When there is a mistake, always there is a kind of unintentional medical error. (to the nurse) when informed about wrong blood – ask: ―did you stop the blood?‖ say: ―Well done!‖ If she asks not to tell the patient...ask her what her believe she may lose her job, and it is too early to determine who is responsible. Errors take place in medical practice. We don’t know what exactly

happened. We will stabilize patient and ensure he’s fine and later deal with this issue. Remove blood unit and keep cannula (to the patient)INTRO:

I am the doctor in charge, and it looks like it was an unintentional medical error took place. We need to make sure you are stable. We don’t know who is responsible, there are at least 15 steps and in each step could have been an error. We will fill an incident report and as soon as we get result we will inform you. You can sue, it is your right at the moment it is my priority to stabilize you.

I will start PRIMARY SURVEY:,

ABCD A – Open your mouth (check for anaphylaxis, no swelling in mouth, ask for any itchiness, or difficulty breathing), Oxygen saturation.

Normal air entry. Normal S1, S2 VITALS: Pleaese . Remove blood unit and keep cannula C: Start new IV line.

Once new line, don’t give fluids if stable. Send blood: CBC, Lytes, INR, PTT, LFT, Cr, BUN, FDP, Haptoglobulin, Direct coombs test; Urinalysis: hemoglobulinuria Unit to be sent to blood bank for cross matching. Ask nurse to call the blood bank and keep original blood. D D1 – I’d like to shine a light in your eyes. Pupils are round, active, and symmetrical. Squeeze my finger, wriggle...wriggle... D2 – (if febrile) give tylenol Please prepare for me : •Benadryl (Diphenhydramine) 50mg. •Steroids (Hydrocortisone) and •Epinephrine SECONDARY SURVEY: Hx (two parts:) 1.Condition (how is he feeling now) 2.―Why blood was given?‖

CONDITION:

Check out for Anaphylactic shock: Do you feel warm? Chills? Itchiness? Tinglings? Diffculty breathing? Wheezing? Swelling in lips / fingers? Hives? Before transfusion did you have fever? Check for Haemolytic reaction – any back or flank pain? P/E – no oozing at IV line Then press on flank and back – no pain for haemolytic reaction. Is it the first time? WHY did you receive blood? If received blood before – was there any complications? Any long term diseases? COUNSELLING:

Mr. X what do you know about blood transfusion? It is a life saving measure, and a lot of measures are taken to make sure it is safe. However, like any other medication with blood transfusion there could be side effects, and these side effects could be serious.

The most common side effect is: •Febrile reaction (3%), usually it is self limited and can happen again. Next time you receive blood we will give you tylenol.

•Anaphylactic reaction. It is a severe allergic reaction, and it is very serious and we cannot predict it. However, we have good measures to deal with it, and your symptoms make it less likely that you have had an anaphylactic reaction. The third reaction is more serious and called •HEMOLYTIC reaction. Usually happens when patients receive blood belonging to another blood group.

The fact that this blood is same as your blood group, and the symptoms are not consistent with haemolytic anemia make it less likely that this is not the case here. The blood is sent to the blood bank and once results are back we will get final confirmation, we will able to reassure you.

Son has anaphylactic shock, is stable now.



Next few minutes I’ll talk with you and hopefully will come to a good plan.

Yawning – give empathy. Hx (Short)

It happened at home you should take history.

If not – don’t take history.

•Itchiness, • Swelling, • Hives.

•Was he able to talk, wheezing, chest tightness, • Lost his consciousness, • Turned blue?

Start immediately with Epinephrine.

What have you done at the event? What did they do?

Any other children at home with anaphylactic shock?



Management Based on the Hx your child has anaphylactic shock.

Explain: a kind of severe allergic or hypersensitivity, from birth or develop later. Usually people get allergic to foods, medications, or chemicals.

Any questions?

At certain stage the immune system starts to interact with some elements of the peanut which are called antigens. From now on when your son will be exposed to the same antigens it will lead to release of some chemicals which will affect his skin, widening blood vessels which will become leaky and different parts of your body will become swollen.

When not enough blood will reach the brain it will lose conscious, difficulty breathing. The concern we have is that it might happen again. It is common.

Plan: the best treatment is prevention.

After that I need to go and talk with your child.

•You have to check the ingredients of any food you buy – make sure it is peanut free. •IF there are other children at home they must be informed as well.

•In case that your child was exposed to peanuts by mistake, you should use EpiPen – this is a special pen, has a cap at the top, which is needed to be activated by removing the cap, press it against his thigh for ten seconds. This increases the blood pressure for about 20 min, in that time you should seek help.

•Your son should carry with him two pens – one at home and one on his bag. • he should carry Med Alert. In case your child become unconscious • I will refer him to allergist specialist. •Aspirin, stress test, and imaging...

•Some children will outgrow it.

Marijuana Counselling



(Mother comes in to see you as she has discovered Marijuana in her son’s belongings)

INTRO:

As I understand you’re here because you’re concerned about your son.

What is his name?

What is your concern?

How much did you find?

Did you ask him about it?

•WHAT MAKES YOU BELEIVE IT IS MJ ?

Is he using it? Or Is he carrying it?

Is it the first time you’ve found it?

•Did you notice any CHANGES in his behaviour?

Is he excited?

Laughing out of nowhere?

Is he preoccupied?

Does he stare at a wall?

Does he talk to himself?

Is he aggressive?

Any problems with the law?

Any fights?

Any criminal records?

Is he more isolated?

•How is his MEMORY?

Is he more forgetful/lose his stuff?

Does he take more time to react?

Does he spend more time in his room?

How much time do you spend with him?

How much time is he out of the home?

How much time does he spend with his friends?

Do you know any of his friends?

What kind of activity are they involved in?

•Does he have a lot of MONEY?

Does he ask for money?

Do you believe he steals money?

Do you think he smokes/or drinks alcohol?

•How would you describe his MOOD?

Is he depressed?

Is he still interested in his hobbies?

Does he worry a lot?

Does he have excessive fears & avoid situations?

Do you have concerns that he may harm himself or anyone else?

EDUCATION:

How is he doing in school?

Have his grades dropped?

DIET:

How is his general health?

Have you ever seen a psychiatrist? Fhx: SAD COUNSELLING:

Based on what you’ve told me.There are no changes in his health & behaviour (assumed that there were no changes in behaviour as per mum) When it comes to Marijuana it is a commonly used drug by teenagers, sometimes only once for experiment. When we talk about Substance Abuse & drugs we talk about different categories. Marijuana is a SOFT DRUG,others like: Coccaine,Heroin& Amphetmanies are HARD DRUGS Let us talk about Marijuana first.

It is from the Cannabis family & affects the brain by feeling happy, excited & enhances experience.Sometimes with prolonged use or in high doses can cause side effects including apathy.

It interferes with memory,& can interfere with his studies & function & fine motor skills & may not be able to operate machinery It impairs judgement & he might take risks. Can cause Lung cancer

In some teens,in high doses unmasks schizophrenia & cause psychosis Interferes with sexual function & can cause infertility & weight gain

By itself marijuana is not strongly addictive & hence he can stop it at any time with help.One of the concerns of Marijuana though is it acts as a bridge to Hard drugs which are addictive i.e you’ve to increase the dose to have the same effect,which is called “TOLERANCE”,& then one cannot stop the drug as it causes withdrawal .

It is a crime to use,hold hard drugs.People can lose their jobs.

If injected increases risk of HIV,Hepa B & C

PLAN

If you like,bring your son here I can talk to him.

It is better to be a confidante to him. Try to be close to him, someone he can trust & can talk to.Try to make sure who’re his friends,& make sure you know what he is doing.Keep him busy with activities.

If there are any druh prevention programmes in your community or his school,get him to attend them & gets the knowledge.

In case of the resident who was asked to backup his supervisor orthopaed

7.I am competent – to emphasize

8.Short term – we don’t have time so we need to see her urgently

9.Long term – solve the situations that it wouldn’t occur again

Pregnant 35 YO has concern about breast feeding.



Tell me more about your concern.

Is it: General information you like to discuss or some specific concerns?

If worried about pain: Ask:

Have you ever been pregnant before?

Have you ever breast fed before?

What makes you believe it is painful?

In addition to that any other concern?

Mostly my concern is...

It is a good concern,& I’m gald you came in today.

How is your pregnancy?

When was your last F/U?

When is your due date?

Let us talk about the pain.....

Breast feeding is a natural physiological process & usually it does not cause any pain.

However, sometimes it might cause some discomfort.

If it pains there should be some reason for that.

Most of those causes are treatable

Most commonly – cracks and fissures. They are caused because of not proper care of the nipple.

You have to make sure that they are moist, clean them, and don’t use soap.

To learn appropriate technique it might take some time.

I can send you to some classes that might guide you.

Retracted nipple and inflammation of the breast (mastitis) you can still continue to breast. Localized condition, like abscess, we still recommend to continue to feed breast from the other side. Before we proceed further I’d like to make sure if you are a good candidate for breast feeding.

Do you have any long term diseases,

Do you take any medication or radiation,  Do you smoke or taking any drugs, Have you been screened for TB or HIV.

Do you plan chemotherapy or radiation therapy?

Based on what you’ve told me,you’re a good candidate for Breast feeding COMPARE BETWEEN BREAST MILK & FORMULA

The reason we recommend breast feeding is that we cannot match it with formulas. The first 24 hours secretion is “ Colostrum” ,it is a special kind of milk& has a lot of antibiotics, immunoglobulin & essential amino acids, which are essential for your baby which will give him protection.

With time the milk becomes more mature and suits the needs of your baby. It has the right amount of carbohydrate & fat. The quality of the fat is better. It has more whey relative to casein. The iron is less than cow milk but is more available (50% as to 20%).

Less load on the kidneys

There are other benefits to your baby and you – there is emotional connection which is important to both of you.

Babies breast fed have

•Less chances of having allergies

•Less chance of having diarrhea

•Less chance of being obese

•Less ear infection,

•Some studies even suggest that they might have higher IQ.

There are some benefits for you (the mom)

It helps to lessen the postpartum bleedings (because the oxytocin) the uterus go back to it’s size Helps you to regain the figure you’d prior to pregnancy. It is clean, available, always at the right temperature, even though you don’t pay for it – It is one of the most important things you can give your child. If chooses to breast feed:

I will send you to clinic who will teach you.

At the beginning the breast feeding is on demand & with time it regulates ,& you need to feed every 3 – 4 hours & at least 10 min in each breast.

Monitor weight gain to ensure that the baby is adequately fed. Occasionally the baby may be jaundiced & sometimes stool may be loose. If you choose to breast feed you’ve to be careful whenever you take medications or alcohol.

You can go back to work, after the Maternity Leave (ask for how long) Breast feeding can be continued. You can use some special pumps. Even if there is engorgement you can use the pump. Make sure it is always clean. Breast milk can be stored at 6hr in room temp, 24 hr in fridge, and 6m in freezer. Don’t put it in the microwave for heating.

Breast feeding is not reliable method of contraception. Recommend the minipill or barrier method.

Febrile Seizure

A child brought to the ER because of febrile seizure.Next 10m counsel him.

EVENT

TRIGGER r/o meningitis.

EDUCATE & what to do next time INTRO:

As I understand you’re here because your child had a seizure 20 minutes ago,& my colleagues are looking after him & he is stable. During the next few minutes I’ll ask you few questions, and after that I’ll go with you to see him.

EVENT:

•Describe the event.

•What happened?

•Did you see him? (Started to shake. All over his body? Bite his tongue / rolling up his eyes / wet himself).

•Did he fall from a height?

•How long did it last?

•Did he stop seizing by himself or did he need medical intervention? •How did he regain consciousness?

After the seizure does he have any neurologic deficits: •Was he drowsy

•Did not recognize you

•Able to move his arms & legs Is it the 1st time? Or happened before If first time:

Ask about fever?

(if it started a week ago – did you seek medical assistance? Any ear discharge? Did they give you any treatment? Did you give it to him or no?)

Why! Some studies show you can treat OM without antibiotics. If reason medication not given was because parent was busy.....You should look for the reason not to give the antibiotics (negligence?). Was he playful,eating,drowsy,

Is he having any vomiting?

Skin rash?

Coughing & phlegm SOB, Wheezing Foul smelling urine & painful peeing Head to toe...

If you find nothing – ask when he got his last shot? (up to 72 hours he can have fever). •R/O meningitis, pneumonia.

•Any family history of febrile seizures, epilepsy BINDE (especially immunization to R/o Measles)

COUNSELLING:

Most likely on what you’ve told me, your child has condition called febrile seizure (FS).Do you know what it is?

It is a special condition in children that might happen from 6m to 60m. We don’t know exactly why – we believe it is a sudden change in the temp & as the brain is not developed fully thes e changes might lead to the seizure. This condition might happen again. The best treatment is:

PREVENTION

Therefore from now whenever your child has a temperature Seek medical attention. Give Tylenol and sponge bath to decrease his temp.

Most of the children will outgrow this condition by the 6th year.

Chances of epilepsy later in life are higher

In FHx of epilepsy,it is a risk fct for development of epilepsy.

They don’t recommend Diazepam because it might make him drowsy. I will give you brochures

If it stopped less than 5m or more than 5m including neurological symptoms seek ER immediately. Brochure.

 

  PHONE CASE:

br>
“This is Dr. ... (immediately should introduce yourself). I am the Dr. In charge in the ER.As I understand, you’re calling as your child has swallowed some medication. I know that you’re stressed & it is a difficult time for you. I need your phone number now & it is important, as if we get disconnected I will call you back.

What is your address?

How far away from the hospital are you?

Try & stay calm. Your son needs you, I am going to give you some instructions and you need to follow them.

FIRST STEP:

Is your son is alert or not?

Is he conscious?

Can he talk to you?

Can he recognize you? (If he doesn’t – do you know how to do CPR and start with that.) He’s crying?

What is his colour? Pink?

Hold him and try to calm & soothe him.

Try to hold him and check his mouth,if there are medications there,remove them.

Is he breathing?

We’ll send the ambulance for you.

When did it happen?

How long was he alone?

Which medications did he take? Whose medications did he take?

Do you have the container?

(Don’t go to the next room to bring them,when the paramedics arrive then you can go & get the container).

Do you know what condition your father have (was it vitamins, sleeping pills, or any other?) How much the amount?

Don’t use any ipecac? Do not induce vomiting.

Is it happened before?

What is the weight of the child?

BINDE (was it full date, did he needed special attention after term, and does he have any special conditions). Weight for two reasons – antidote and estimate neglect.

Are his shots up to date?

Are there other children at home?

Have you visited the Er frequently?

Post encounter Q: what are the first four steps you do when he arrives?

ABC,

Monitor vitals,

IV line, NG,

Foley as needed,

Blood works – CBC, Lytes, BUN, Cr, Osmolality, Coagul, LFTs, Tox screen – blood and urine).

List three risk factors forneglect for this child.

What is the antidote for betablocker (glucagon) and for CaChannel is (Calcium gluconate). CAS & Poisoning centre.

Second scenario Phone case: Febrile Seizure

This is Dr. ... (immediately should introduce yourself). I am the Dr. In charge in the ER.As I understand, you’re calling as your childis having a seizure. I know that you’re stressed & it is a difficult time for you. I need your phone number now & it is important, as if we get disconnected I will call you back.

What is your address?

How far away from the hospital are you?

Try & stay calm. Your son needs you, I am going to give you some instructions and you need to follow them.

While he is seizing just put him on the side, and not start any CPR. Is he seizing right now? Try to put him on the floor on the left side (the right bronchus is shorter than the lt.).

Observe him.

What is his colour?

Is he still shaking? You send the ambulance.

Can you tap on his shoulder?

If he is not responding – can you do CPR?

Can you feel his pulse? If stopped seizing...... Good Is he alert? Does he respond?

Can he talk to you?

Can he move his legs?

EVENT:

Can you describe what happened?

OCD

Fever +/-

Does your child have fever?

Did he have Hx/Nx/Vx/Skin rash/Neck stiffness Any long term disease?

Did you seek medical attention? What prevented you from giving the medication?

Is it the same time or happened before. If it is the second time – more than 15m he needs intervention.

Post Concussion



Hx & PE

INTRO:

As I understand you had a head injury 3 days ago when playing hockey. Start with EVENT: Before & After If LOC ask How long?

Do u remember what happened? What was done?Were you hospitalized?

Was a CT Scan done?

HOW DO YOU FEEL TODAY? Full neuro assessment Headache:

OCD PQRST U V A&A

Vomiting,bending,Nausea

Balance,vision falls weakness numbness Difficulty finding words Past Med Hx:

HEADDS

PE:

Vitals

CN

Power

Reflexes

Sensory

GAIT check Tendem gait

Conclusion:

I know you’re eager to play hockey

Since you’ve headache you’re not ready to play again as you still have active Sx. If you start to play again your tolerance for injury is lower & if you are injured again,your tolerance is lower & recovery time is longer & there might be serious consequences. Why don’t you wait till full recovery time

I will refer you to a PT & with gradual step up exercises you can get back to your game: One week with warming up, after that stationary activity, after that skiing, than drilling without contact (seven steps of rehab.).

Osgood Schlatter

2 scenarios (Osgood schlatter and Post-concussion)

Decision will based whether the child can tolerate pain or not?

#1 About to see the father of 14yom with Osgood Schlatter.

Make sure that the child best interest are preserved. What was done to diagnose the child?

OCD PQRST compare to the other knee, is the first time or not, was any trauma. What is the child wish? (Don’t go for HEADDSSS since it is the father).

Counseling

What is your understanding of OS.

Let me explain to you what is the mechanism for OS.

Avoid him from playing, especially jumping. But he can continue with ice presses and pain killers. The rule is that he can continue up to his limit of his pain.

  IMMUNIZATION

br>
(Newcomer come to Canada from Ukraine, concerned about immunization) May need interpreter: Ask:

Do you understand?

Can I talk slower?

Do you need interpreter?

INTRO: As I understand you’re here as you’re concerned about vaccines & my understanding is that you’re new to Canada, Welcome to Canada!

What is your concern?

•Pt: My neighbour told me vaccines are not safe Dr: what do you mean?

Pt: Concerned about autism & vaccine

Dr: This is a reasonable enough concern,& I’m glad you came here.

There is a misinformation about between vaccines & autism.The origin of this misunderstanding is due to a study done in the UK & the author of that study found a connection between autism & vaccines. Because vaccines are lifesaving & important for our children’s protection,further studies were done,also in other countries,& then it was definitely proved that there is no connection between autism & vaccines.The only connection was coincidence between time of the vaccine & time when symptoms of autism were picked up by parents.

•Another common concern is that mercury was used as a preservative for MMR vaccine. It is no longer used now.

When we find out why this study gave such a result it was found out that there was a bias in sample & thus led to the wrong conclusion.

•Another common Qn pt may ask:

These diseases do not exist in Canada, so why give my child the vaccine if there is no disease here.

The world is getting smaller & even though we do not have these diseases in Canada, because we have the vaccines, it does exist around the world & people travel.So we do not want your son to get affected whenever there is an outbreak somewhere in the world.

Hx: Let me ask some questions about your son:

•How old is he?

•Has he received any vaccines so far?

•Were there any side effects?

•Any reason why he was not vaccinated?

•Does he have any congenital medical condition? • Does he have any allergies (egg??)

• Any neurological history?

Inform that baby is a good candidate

As I told you vaccines are life saving, before vaccines many children died from measles, rubella. The reason being children are not fully protected & may get the infection & die. Once vaccinated, children get the immunity Any Qns?

HOW:

We take different bugs like bacteria, viruses or products of these bugs & process them so that it does not harm the body,& inject it into our bodies by needles. Our body reacts by forming elements that fight these antigens, so later in life when your son is exposed to the real factor, these antibodies will protect him. Some of these antibodies will last forever; some will need booster doses.Because there are a lot of disease we need to minimize the number of injections & we’ve to give greater than one needle for vaccination. There is a combination vaccine e.g: PEDISIL = DPT + HiB + Polio This is given as a single shot at 2,4,6 & 18 Mo.

We will give you a schedule to remind you each time you’ve to come to the clinic Concerning the SIDE Effects, the benefits clearly outweigh the S/E,however: A febrile reaction can develop & you can give Tylenol if this occurs Pain & swelling at injection site

Some children can have prolonged crying

Others may become floppy

In still rare conditions can have a seizure

Very rarely,can gt an anaphylactic reaction

Since you’re a newcomer & not got your insuarence there are some organizations that will help you out.

IUGR



INTRO:

As I understand you’ve just given birth to a baby,& my colleagues are looking after

him,& I’m here to talk to you.

How do you feel right now?

Have you seen your baby?

Did anyone tell you about your baby?

If at this point mother voices a concern that she saw her baby covered with green stuff. Your baby was covered with “Meconium” one of the substances in the fluid surrounding your baby.It is normal for the baby when under stress during delivery. I’ve been told that your baby has a condition called “IUGR”,& I need to ask questions as to why it happened Qns about Pregnancy: Smoked/Alcohol/Drugs Qns about Delivery:

Term or preterm MGOS:

O:Previous pregnancy/abortions/miscarriage, & if yes how many?

G:If Hx of Cancer or chemotherapy

Any congenital disease in her or husband’s family or Consanguinity If she asks whether her mistake:

Don’t reproach her – it is NOT her mistake.

It is a multi-factorial condition. Can be due to various causes, some genetic, pregnancy, related to baby

Because safe levels of smoking, drugs & alcohol not known, We always recommend not to smoke or drink for future pregnancies.

CHILD ABUSE:

br>
•# Femur

•# LE & (B) limbs

•Spiral #

•# post ribs

1.EVENT

2.1st time or prior

3.BINDE:

4.Past MH for osteoporosis imperfecta

4. COUNSELLING

INTRO:

As I understand you’re here as your child had a #.My colleagues are looking after the child, who is stable now.

EVENT:

How?......Describe what happened….if fall from couch: How high is the couch? When? …If time log……Why bring the child now??? If at night? Did he sleep or was he crying?

Were you there?

Did you see it?

Any LOC?

Is it the 1st TIME or has it happened before?

If before?

How many times?

Type of #?

Did you come to the same hospital or to a different one?

Any other children at home?

BINDE:

Planned pregnancy

Term pregnancy

Any cong anomalies

During pregnancy: SAD

Immunizations up to date or not

Weight today

Development: Is he a difficult child?

Environment:

PARENT-CHILD RELATIONSHIP:

Stress at home

Who is primary caregiver or who feeds the child?

How do the parents punish the child?

Financial problems

SAD

Any Psy Hx in either parent PAST MH:

Here specifically ask about Osteogenesis Imperfecta

Counselling

I can see that you’re going through a difficult time. Sometimes it is challenging to work & care for a child. From the history you gave me about the injury is not enough to explain such an injury. Children at this age have very flexible bones which are difficult to break by jumping off the couch. I’m sure you share my concerns with me about the safety of your child & in this situation we contact the CAS. The CAS will come & ask questions & talk to you & your partner:

If does not accept & says will take my child…….

Ask what makes you think like that? Do you have any experience about these matters? It is not neccassarily,they will asses the situation & if the family is considered safe… If pleads etc: Tell I’ve a legal responsibility to report to the CAS



  SUICIDE ATTEMPT 16/F suicide attempt ASA overdose

Sex:

AGe

Depression

Previous attempts

Ethanol use

Rational thinking loss

Suicide in family

Organized plan

No support (here put HEADSS)

Serious illness

INTRO:

As I understand,you’re here because you overdosed on Aspirin last night & I’ve been told that you’ve been seen by my colleagues.My understanding is that you’re stable now,& I can talk to you.

HOW DO YOU FEEL RIGHT NOW?

(if she is playing around with phone etc ask her to disconnect & speak to you) Can you tell me more about what happened?

Pt: I went home & took Aspirin Dr; why?

Pt: I was frustrated Dr: Why?

I can see that you’re busy with your phone,is it important?

Can you stop for a few minutes?

I’d Like you to know that whatever you tell me is confidential here

Give confidientiality Dr: Why are you angry? Pt:I made a car accident When?

Were you alone,or with someone else?

Were you driver or passenger?

Was anyone else hurt?

How Much aspirin?

Did you talke aspirin alongwith any other medication?

Did you lose consciousness?

Who called for help?

Did You seek help ort someone else did?

Was it IMPULSIVE or PLANNED?

Did you leave a note?

Have you recently been giving away your belongings to others?

Is it the First time?

Any suicidal attempt in the family?

Do you usually take alcohol,or take drugs?

R What did you think about ending your life?

R/O Psychosis:

Sometimes when people want to end their lives they see a vision or hear voices,did you experience any of such?

How is your mood, for the LAST 2 WEEKS (last 48 hrs make no difference)

HEADDSS

Do you have a driver’s liscence?

What made you take the car?

It seems an important trip, where did you go?

After you leave the hospital, what do you plan to do?

Finish SAD PERSONS

If parents separted ask about the other parent

If score <4 can send home

Nancy I know this is a stressful time for you.Based on the interview I think it is OK for you to go home. Do you feel safe at home?

PT: Would you tell my mum?

Dr: Why can’t you tell her?

How is your relationship with your mother?

I do see your point,& it is better you tell her yourself,I can help you delivering the news.we can arrange a meeting where a social worker be present & you can deliver the news. Life is stressful & you’ve to learn how to handle these situations in the future. I also want you to know in the future you may face a similar situation & if you ever feel like this again,Please seek help

Call 911,go to the ER,Talk to your Family Physician



ANOREXIA NERVOSA

Here inform parents as Pt lacks insight

*In Bulimia do not inform parents Pts can have Borderline personaliy disorder,Depression,Impulsive behaviour or Kleptomaniac.

Here ther is Loss of Control, Large amount of food within 2 hrs & then feels guilty & induces vomiting + excessive exercise 2/week x 3 months

INTRO:

Hello,as I understand you’re here today as your parents are concerened about your

weight Can you tell me more about their concern?

What about you?

I’m glad you’re here today,as I can reassuare your parents

*WEIGHT

1.When did you start losing weight?

2.What was your weight when you started?

3.What was your highest weight?

4.What is your target?

5.When you look into the mirror,how do you perceive yourself?

6.Do you like to dress in baggy outfits?

7.Why do you want to lose weight? (Often carrer choice is of,Model,dancer or actress)

8.How do you plan to achieve that?

* DIET:

1.How’re your meals?

2.What snacks do you take?

3.Analyse the meals

4.How many calories?

5.Do you eat alone or with others?

6.At any time did you lose control & consume a large amount of food which is more

than normal?

7.& how did you feel with that?

8.Did you try & compensate by exercise or purging?

* EXERCISE:

1.How long and often do you exercise?

2.What other activities are you involved in? E.g: dancing,walking

*Any other measures to lose wt like:

Water pills,medications like Xenical,Meredia,stool softeners?

*How has this IMPACTED your health?

1.No periods? For how long?

2.When was your last period?

3.Heart racing at night? Muscle cramping at night? (Hypokalemia)

4.Dry skin?

5.Constipation?

6.Fine hair on your body?

7.Pigmentation on your legs?

8.Any bone pain or fracture?

*MOAPPS

*HEADDDSSS

 

22 /F Somatization disorder

If seen by a surgeon – suspect somatisation. INTRO:

As I understand you’re here because you’ve abdominal pain for 3 weeks Can you tell me more about it since it first started?

What did the surgeon tell you?

What investigations were done?

What Diagnosis was given?

Analyse pain TODAY

OCD

(PQRST) Non Specific

During the day or night.

U:How has it impacted your life?

How are you coping with It?

What happens at work

V:First time to have this pain or had it before If BEFORE:

When

How often

Similar type

Seen by Dr?

Any Interventions?

CSx

Jaundice, white stool and dark urine Foul smell, bulking, droplets in stool Awakens at

night?

Nx/Vx

Change in bowel movement?

MRI – why do you think it is important?

To differentiate: Somatic pain disorder / Somatization

In addition to abdominal pain: do you have:

Any other pain?

Headache, joints, back, pain with intercourse With whom do you live?

Are you sexually active? Any pain with IC

How is your interest in sex?

Do you feel interested after sexual activity?

NEUROLOGICAL:

Do you have tingling/numbness?

MOAPPS:

How is your mood?

Organic

Self Care? With whom do you live?

Is your partner supportive?

How do you support yourself?

Any FH of suicide?



 

 

 

 

39 YOF Pregnancy. Counseling. 10m

Hx=4min

Counselling = 6mins

35yo – 1:180 (congenital) – half of them Down synd (1:360)

45yo – 1:45 (congenital) – 1:20 Down (5%)

•Always ask about concerns

•Why worried about Down’s

Take Hx: Age/FH/Ca/Cxt/RXT/Medications

M: LMP + Sx of pregnancy +Pregnancy test G

O: Imp

S

Past MH: Risk Fcts

FH: Congenital

EDUCATION:

CVS Amniocenthesis

Accuracy Age

S/E:

Results:

Risk of abortion: 97%

10-11 wks

Limb defec

ts 48 hrs

2%

-- 99.9%

14-16 wks

-- 2 weeks

0.5%

Checks for other conditions



INTRO: As I understand you came here today, because you found out you were pregnant last night & have requested an urgent meeting with me. What is the reason? Not ask if it is planned or not.

Ask if was on any contraception.

Confirm pregnancy by exact date.

What do you feel about the pregnancy?

What is your concern?

If she says it is her age or concern about Down;s Ask: Any experience with Down’s syndrome?

Any Fhx of congenital anomalies?

It is a reasonable enough concern & I’m glad that you’re here. There are some

measures we can take to screen for some deformities, yet it is not 100%

How do you know you’re pregnant?

When did you find out?

LMP

Sx of pregnancy: Nausea/Vx/Breast tenderness/Inc visits to wash room to pee.

Prev pg?

Any contraception?

PAP’s smear?

STIs?

FH of Cystic fibrosis

Did you discuss this with the father of the baby?

Any reason why not?

Past MH:

Medications

Chemotherapy

Radiotherapy Smoke/Alcohol/Drugs

COUNSELLING

If wants abortion,shift to abortion.There are some important figures you need to know Most of the time we’re concerned about Down;s SyndromeUsually the risk of having a child with congenital. Abnormality at the age of 35 is around 1:180 and half of these children are DS.

To r/o we do a test called amniocentesis, and the reason we offer it is because the risk of complications of miscarriage is lower than the risk of congenital abnormality. 0.5% (abortion) compared to 0.55% for DS.

If not willing then go to amniocentesis.

We can arrange for it. First we confirm pregnancy by US to get the exact date. Then insert a fine needle guided by US into the womb & take sample of the fluid surrounding your baby and send it to the lab. Usually we do it around 14-16w and the results will come around 2w later. It is very accurate >99%. Help us to r/o other conditions is very safe. Like neural tube defects Risk of abortion is very low < 5%. At the age of 35 the risk of having a miscarriage due to amniocentesis complication is less than the risk of having a child with a congenital anomaly.

As always in medicine, we’ve to find a balance between risk & benefit. If pt wants an earlier test.

Another option, not commonly done is Chorio venous Sampling Here risk of abortion is 2%, & thus higher than amniocentesis.

The results are back in 48 hrs,however the chances of having a high false negative is 3% when baby is still affected Also there is a risk of limb injury

Genetic abnormalities: cystic fibrosis, thalasemia, etc. For that reason you should be referred to a genetic counselling.

From Mayo Clinic:

Amniocentesis is a procedure in which amniotic fluid is removed from the uterus for testing or treatment. Amniotic fluid is the fluid that surrounds and protects a baby during pregnancy. This fluid contains fetal cells and various chemicals produced by the baby.

With genetic amniocentesis, a sample of amniotic fluid is tested for certain abnormalities — such as Down syndrome and spina bifida. With maturity amniocentesis, a sample of amniotic fluid is tested to determine whether the baby's lungs are mature enough for birth. Occasionally, amniocentesis is used to evaluate a baby for infection or other illness. Rarely, amniocentesis is used to decrease the volume of amniotic fluid.

Although amniocentesis can provide valuable information about your baby's health, the decision to pursue invasive diagnostic testing is serious. It's important to understand the risks of amniocentesis — and be prepared for the results. Before amniocentesis, you can eat and drink as usual. Your bladder must be full before the procedure, however, so drink plenty of fluids before your appointment. Your health care provider may ask you to sign a consent form before the procedure begins. You may want to ask someone to accompany you to the appointment for emotional support or to drive you home afterward.

During the procedure

First, your health care provider will use ultrasound to determine the baby's exact location in your uterus. You'll lie on your back on an exam table and expose your abdomen. Your health care provider will apply a special gel to your abdomen and then use a small device known as an ultrasound transducer to show your baby's position on a monitor.

Next, your health care provider will clean your abdomen with an antiseptic. Generally, anesthetic isn't used. Most women report only mild discomfort during the procedure. Guided by ultrasound, your health care provider will insert a thin, hollow needle through your abdominal wall and into the uterus. A small amount of amniotic fluid will be withdrawn into a syringe, and the needle will be removed. The specific amount of amniotic fluid withdrawn depends on the number of weeks the pregnancy has progressed.

You'll need to lie still while the needle is inserted and the amniotic fluid is withdrawn. You may notice a stinging sensation when the needle enters your skin, and you may feel cramping when the needle enters your uterus. The entire procedure usually takes about an hour, although most of that time is devoted to the ultrasound exam. In most cases, the fluid sample is obtained in less than two minutes. The small amount of amniotic fluid that's removed will be replaced naturally. After the procedure

After the amniocentesis, your health care provider may use ultrasound to monitor your baby's heart rate. You may experience cramping or a small amount of vaginal bleeding immediately after the amniocentesis. Your health care provider may suggest resting after the procedure. You may want to ask someone to drive you home. You'll likely be able to resume normal activities the next day.

Meanwhile, the sample of amniotic fluid will be analyzed in a lab. For genetic amniocentesis, some results may be available within a few days. Other results may take one to two weeks. Results of maturity amniocentesis are often available within hours.

If you develop a fever after amniocentesis or if vaginal bleeding, loss of vaginal fluid or uterine cramping lasts more than few hours, contact your health care provider.
 
 
 
 
 
39 YOF HSIL 
ASK HER ABOUT RISK FACTORS
In Lab work you always ask Why?

And is it the first time?

SPIKE

Explain

Local symptoms

CSx

MGOS

PMHx

Plan (colposcopy)



INTRO:

...because it is the first time I want to ask you some questions so as to get a better understanding of your results.

Why? Is it the first time? When was it done?

Any reason prevented you from doing it?

What was your result at that time?

If done long ago?

Some people want to know in

Are you the kind of person who prefers to know all the details about what is going on?

How much information would you like me to give you about your diagnosis and treatment?

Would you like me to give you details of what is going on or would you prefer that I just tell you about treatments I am proposing?‖ If not anxious:

What do you know about Pap smear?

Yes, we look for changes in the cervix including cervical cancer What do you know about Ca Cx?

It is a common cancer & we pick it up with Pap’s smear & if detected early, outlook is good

What are your expectations of today’s visit?

The results are back & ―I wish I had better news for you but unfortunately it shows you have some changes in the pap smears, & these changes are called ― HGSIL‖.& these changes if Ca or not are not detected by PAPs smear. We need to do further assessment to determine whether it is Ca or not.

Let me ask you some questions to see if you have some symptoms related to it:

Local, Meta, Constitutional

LOCAL: Vaginal bleeding/Discharge/Ulcers/Blisters/Warts?

Pain with intercourse Bleeding with intercourse

Lumps, bumps in groin area?

Fever,wt loss,Back pain?

MGOS

M:At which age you had your first period, G: Any Gyn surgery Contraception?

O: Have you been pregnant?

How many times?

At which age was your first pregnancy?

S: At what age were you sexually active?

How many partners did you have?

With whom do you live? How long have you been in this relationship?

Before this relationship,How many partners did you have?

STDs, Smoke,

How do you support yourself financially

Past Medical Hx

Family Hx

―I have bad news. The colposcopy result came back and consistent with cervical cancer.

We need to take further steps & I will refer you to a gynaecologist.

If you want future babies they will use local options & do something called a Cone biopsy

If you do not want any more children the uterus & cervix will be removed & the prognosis is excellent
 
 
 
 
 
 
 
Allergic Rhinitis, Counsel

Intro

OCD

(seasonal: caused by pollens from trees. Summer, spring, early autumn – usually last several weeks, disappears and recurs following year at the same time; Perennial: occurs intermittently for years with no pattern or may be constantly present);

P: is the nasal congestion is only in one side (allergic rhinitis) or varies from side to side (vasomotor rhinitis)

COCA-B (should be clear rhinorrhea, under microscope it contains increased eosinophils); Watery/mucoid: allergic, viral, vasomotor, CSF leak (halo sign) Mucopurulent: Bacterial, foreign body

Serosanguinous: Neoplasia

Bloody: Trauma, neoplasia, bleeding disorder, hypertension/vascular disease

ΑA: Allergic rhinitis (hay fever): most common inhaled allergans - house dust, wool, feathers, foods, tobacco, hair, mold; most common ingested allergans – wheat, eggs, milk, nuts;

Vasomotor rhinitis: caused by – temperature change, alcohol, dust, smoke, stress, anxiety, neurosis, hypothyroidism, pregnancy, menopause,

Drugs: parasympathomimetic drugs and estrogens (OCPs, HRTs);

Beware of rhinitis medicamentosa: reactive vasodilation due to prolonged use (>5 days) of nasal drops and sprays (Dristan, Otrivin)

ΑSx: Itching eyes with tearing, frontal headache and pressure, hypothyroid symptoms, change in menstruation (pregnancy/menopause);

MOAPS (especially – anxiety, neurosis, and drugs);

Complications: signs of sinusitis (pain in the face, post nasal drips, fever, severe headaches, teeth pain, PMHx of sinusitis); Ask for diagnosis of nasal polyps or obstruction in breathing through the nose when there is no sign of allergy; Ear pain (especially serous otitis media)

SHx:

Counsel:

From the Hx I’ve just taken it is most likely that you suffer from a condition called: allergic rhinitis/vasomotor rhinitis. This condition is very common and is caused by exposure to irritants in the environment which are called alergans.

These alergans trigger the immune system to release substances which cause the congestion in your nose. Finding and eliminating the appropriate trigger/s can prevent this condition.

For that reason I am sending you to do some allergy testing.

Meanwhile I can recommend several options to alleviate your symptoms.

For allergic rhinitis:

•Nasal irrigation with saline

•Spray, nasal drops, or tablets with antihistamines (e.g. diphenhydramine, fexofenadine)

•Oral decongestants (e.g. pseudoephedrine, phenylpropanolamine)

•I wouldn’t recommend to use topical decongestants since they may lead to a condition called “rhitinitis medicamentosa” which may increase and deteriorate your condition. In case of necessity – you may use a topical decongestant up to five days.

•There are many other medications that might help in case of serious condition – like steroids (fluticasone), or for prevention (disodium cromoglycate), also ipratropium bromide. If very severe oral steroids may be used.

•Desentization by allergen immunotherapy is also an option in some cases.

For vasomotor rhinitis:

•Some relief can be achieved by exercise (increased sympathetic tone)

•Drugs that called parasympathetic blockers (e.g. Atrovent nasal spray)

•In serious conditions – steroids (e.g. beclomethasone, fluticasone) •There are also some invasive procedures that might be used in stubborn cases. Surgery (which is often with limited lasting benefit), electrocautery and cryosurgery which use hot or cold instruments to affect the lining or your nose.

Overall this condition can be annoying but it is not dangerous and there are many ways to treat it. However, in most cases it is repeated and the benefit of each treatment should be well balance against its risks.
 
 
 
 
 
 
 


  Enuresis

Intro, ask about the concern

Ask about the name and age of the child OCD - Analyze the problem:

Since when is he wetting his bed? Is it primary or secondary?

Does the child lose control on his bladder during day or only at night?

When did the child control his bladder and toilet?

How does the child feel about it? How do his caregivers feel about it?

R/O organic causes (red flags):

DM: Drinking too much, going more often to pee, feeling tired, lost weight DI: Hx of meningitis, encephalitis (brain infection), head trauma Seizure

UTI: Dysuria, odd smell or colour of urine

Neuro: Bowel dysfunction, leg weakness or numbness, trauma or surgery to back Stress: Any stress or problem or new event

Others: Sickle cell disease, pinworms, constipation, and the most common cause for diurnal dieresis is micturition deferral

PMHx – including medications (diuretics) and allergies

FHx

BINDE (briefly – because the child is 8-9 y.o)

How was the pregnancy (any problem)

How was the delivery (NVD vs. C/S)

Term or pre-term

Are his regular shots up to date?

How is his nutrition (does he eat well balanced diet)?

How is his school performance?

Who is the primary care giver? Who else live with them at home? Is he the only child?

Counsel

•Explain what is happening – say it is m/p regression of his development because of the current stresses in his life

•It is caused by maturational lag in bladder control while asleep. It is self limiting and you need to give the child some time and he will adapt very well to the changes. About 20% of the children resolve spontaneously each year.

•The prevalence of this problem: 10% of 6 y.o, 3% of 12 y.o, 1% of 18 y.o •Treatment by changing life style: limiting nighttime fluids and voiding prior to sleep, engaging child using rewards, bladder retention exercises, scheduled toileting •You can try a method called ―conditioning‖: ―wet‖ alarm wakes child upon voiding – this method has 70% success rate

•As last resort you can try even medication: DDAVP by nasal spray or oral tablets, but there is high relapse rate and it is costly. Other medical options: oxybutynin (Ditropan), imipramine (Tofranil) – the latter is rarely used since it is lethal in overdose and has cholinergic side effects.

Important Drugs to Remember

Enuresis

Desmopresin 0.2-0.6mg at bed time

Torticulosis

Treatment: Diphenhydramine 50mg

Warfarin counselling

Enoxaperin 20mg OD (low risk)

Enoxaperin 40mg OD (high risk)

Want to stop Li

Normal level 0.5-1.2

 
 
 
 
 
 

Ob/Gyn

OCD (Onset Course Duration)

MGOS (Menstrual, Gynecological, Obstetrical, Sexual) History

Menstrual Hx

How old were you, when you first got your period?

Is your period regular?

How often do you have your period?

How long does it last?

How many pads do you use per day?

Do you experience pain during your period?

Do you have bleeding between periods?

When was your last period? Is it possible that you're pregnant?

Gynecological Hx

Hormonal therapy (for any reason)

Do you use OCP?

Did you regularly have a pap smear done?

When was your last pap smear?

Have you undergone radiation therapy for any reason?

Have you undergone any interventions done such as dilatation and curettage?

Obstetrical History

Have you ever been pregnant?

Yes (in the past)

How many previous pregnancies?

How many living children do you have?

Have you had any preterm pregnancies?

Have you had any abortion or ectopic pregnancy?

Any complications during your pregnancies?

What was the mode of delivery?

Yes (now)

How's your baby's movement?

Any bleeding?

Do you have regular contractions (If yes, how often? How long do they usually last?)

Vaginal dribbling of water?

Are you regularly followed up by a doctor?

Have you had investigations done, such as an U/S or CBC?

Sexual Hx: mention confidentiality.

Are you sexually active?

Since when?

How many partners did you have?

Do you practice safe sex?

do you use condoms?

History of vaginal discharge

History of urinary problem

Abdominal pain

History of STIs

Partner's history of STIs
 
 
 
 


Case 1 OCP Counseling

15y would like a prescription for OCP. Take a focused history and counsel her.

What raised your concern?

How much do you know about OCP? How much would you like to know about OCP?

Assure confidentiality

Specific Questions

Irregular vaginal bleeding, B.P, dyslipidemia, liver disease, leg pain, clotting in the legs,

breast mass, smoking, headache or migraine, family hx of high cholesterol

MGOS

Important questions

Do you ever plan on getting pregnant? When?

Are you a good pill taker?

Do you have any concerns about a particular type of contraceptive?

General Qs

Family History of breast cancer, family history of high cholesterol

Sexual abuse

Social (HEADSSS)

OCP is a hormonal treatment effective in 99% of the cases. It prevents ovulation & thus

prevents pregnancy. It doesn't prevent STIs, For STIs, we recommend that you use

another method such as condoms.

Hormonal contraceptives come in different forms: intramuscular injection, skin patch

and vaginal suppository. OCP are a very convenient method of birth control.

Each pack contains 28 tablets: 21 hormone tablets & 7 sugar/placebo pills to keep you

on track and maintain the regularity of your cycle.

You can start a pack on the first day of your cycle. Take it at the same time each day.

Side Effects:

When you first start OCP, you may experience nausea, headache, breast tenderness, weight gain,

& irregular bleeding. These symptoms are temporary and should disappear with time. If these

side effects concern you, come in and see me.

Benefits of all the hormonal contraceptives:

reduced Anemia; decreased Benign breast disease and cysts; decreased Cancer

(ovarian), regulated Cycles, Increased Cervical mucus which reduces STIs; decreased

painful cycles (Dysmenorrhea), decreases pregnancy outside the uterus (Ectopic)

Keep in mind that birth control pills can alter the effect of other medications. in the

future, you should always inform your doctor & pharmacist that you are taking OCP.

There are some contraindications to OCP. It doesn't appear that you have any of them,

but I need to examine you first, and send you for some investigations.

Do you have any question?

Can you give me a one-year prescription for the pills?

At this time, I'll give you a prescription for 1 month to see how you feel on the

medication.

In case patient asks you not to tell her guardian (for example: mother):

That's completely your decision; however, you may find it helpful to let your mom know,

as she can offer support. If & when you'd like to discuss this with, I could arrange a family

meeting.

Arrange for follow-up

Commitment to plan

Explore other concerns

Additional information on OCP:

In general, you should not take the pill or use the patch

If you already have migraine attacks with aura

If you have a past history of having migraine attacks with aura

If you already have migraines without aura and are aged 35 or above

If you did not previously have migraine, and then migraine attacks first developed after

you started taking the pill or using the patch.

So, in other words, the only women with migraine who can usually take the pill or use the

patch are those who are aged under 35, and who already had migraine attacks without aura

before they started taking the pill or using patch.

There are various other methods of contraception for women with migraine who should not

take the pill or use the patch.

For example, the progestogen-only contraceptive pill, the progestogen injection,

intrauterine contraceptive devices or systems, and barrier methods will usually be

suitable.

If you have the same case, but with no eye contact ---> Sexual abuse

by step father As the same questions as the previous case, plus

sexual abuse questions
 
 
 
 
 
 


Case 2

18y would like a prescription for OCP?

Normal history taking, Positives in case:

Smoker, migraine, menstrual period every 2 months, was 18 years but answered yes for

Pap and result was normal, multiple sexual partners, no safe sex, recent weight gain and

unhealthy life style (Don't forget HEADSSS)

1) Contraindication for OCP in this case?

History of amenorrhea (LMP 2 months ago)

2)Investigations before prescribing OCP?

In this case--- B HCG
 
 
 
 
 


Case 3 (VBAC)

35y women who had a previous Cesarean section (CS) now she wants to know whether

she can have a vaginal birth after Cesarean (VBAC)

Dr: How can I help you?

Pt: I'm pregnant and had a CS before. My friends told me that once I've had a CS, there's no

chance for a vaginal delivery. Is this true?

Dr: In order to better address your concerns, I'd like to start off by asking some questions if you

don't mind.

How do you feel about this pregnancy?

Do you know why you had your last CS?

Did anything happen to your baby?

Do you know the type of Incision?

Do you have the report with you? The pt will have a report showing lower segment

Cesarean section

What about the current pregnancy? any problems?

When was your LMP? Do you know your estimated due date (EDD)?

Are you being followed up by a doctor?

Is it possible that you may have herpes infection on your intimate parts?

Were any test done? Do you have high blood sugar?

Have you had an U/S? Is it possible you're carrying twins?

Is it possible you may have any abnormality of the placenta?

MGOS

General Hx

Counseling

As I understand, you had a LSCS„ With this type of incision, you can have a normal vaginal

delivery with a success rate of up to 80%. Vaginal births have certain advantages over CS such

as less blood loss, shorter stay in hospital and a lower chance of infection

The CS can be an important and life-saving procedure when done at the right time: such as in

the case of when the baby is big, if the mother had active herpes infections on her genitals, or

if the mother's placenta was not in good condition. Also, we may have to consider a CS if you

or the baby were to experience any problems prior to the delivery.

While pregnant, suggest you: eat healthy diet, avoid smoking/second-hand smoking & avoid

alcohol.

Consult your physician prior to taking any medication. Come in for regular check-ups.

Do you have any questions?

Pt: Can I let the midwife delivery my baby?

Dr: Due to your history, I highly recommend delivery at the hospital. In your case, your chances

of potentially rupturing your uterus are higher than normal. If this were to happen, you'd need

immediate medical attention, as this is a very serious condition that may affect you and your

baby.
 
 
 
 
 


Case 4 (Abortion)

22y is 12 weeks pregnant. She has vaginal bleeding. Take a history and counsel her.

OCD

COCA-B: color, odor, consistency, amount + blood

Severity

Dizziness, heart racing, and U urine

Abdominal pain (threatened abortion/ectopic)

Passage of tissue (abortion)

Contractions

Nausia

Vomiting

Did you notice an increase in the size of your abdomen (molar pregnancy)?

Do you bleed excessively from your nose or other sites? Do you have excessive bruises on your body?

What is your blood group?

What's your husband's blood group?

Specific Qs

How do you feel about this pregnancy?

How did you find out that you're pregnant?

Do you have any pain in your breasts?

Morning sickness

MGOS

IUD

history of PID, vaginal discharge

General Hx:

Fever: are you taking blood thinners,

family history of genetic disease, trauma, and sexual abuse

Surgery: Tubal ligation

Counseling

I am going to examine you and send you for some tests. This is a common occurrence during pregnancy. Many women can continue the pregnancy till full-term.

If this were an abortion, it means there may be a problem with the baby. This is the natural selection of your body to eliminate an abnormal pregnancy. This is not, in any way, your fault.

Abortion

Ectopic pregnancy

Molar pregnancy

Bleeding tendency

Sexual abuse

If the U/S shows intrauterine pregnancy, what is your diagnosis? ----> Threatened abortion

If the PV exam showed blood coming out from cervix and US showed intrauterine pregnancy with no cardiac activity, what is your diagnosis? Missed abortion
 
 
 
 
 


Case 5:

(Abortion)

A 6-week pregnant woman complains of vaginal bleeding. Take a focused history.

3 days ago, she went to the hospital because of spotting. Today, she began bleeding profusely. The bleeding has gotten worse and she has abdominal contractions.

She hasn't seen any tissue coming out. She's had a miscarriage in the past. PEP, B-HCG dropped from 235 to 135.

What are your 2 most likely diagnosis?

1. Abortion

2.Ectopic pregnancy

What finding on a physical exam would confirm your diagnosis?

Vaginal exam opened cervix

Bleeding from cervix

She is hemodynamically stable, does not want to have any other pelvic examination. What would you order now to follow-up?

US

B HCG

Case 6

30y is 30 week pregnant and has vaginal bleeding. Take a focused history.

OCD

How do you feel about this pregnancy?

COCAB + severity

Preterm : water broke, any contraction, abdominal pain

Do you feel that the baby is moving?

Placenta previa (no pain)

Abruption of the placenta: is it your first baby, T B.P, headache, blurred vision, any swelling of the face, abnormal movement

-Smoking, alcohol, cocaine

-Low socioeconomic status: any financial problems

-Any Previous infection ?

u/S: any abnormality in the baby, abnormality in the uterus, is it possible you're carrying twins?

Trauma: hx of trauma, sexual abuse

Bleeding tendency: do you bleed excessively from your nose or any other sites?

Uterine rupture: did you have any intervention such as C/S or surgery? Do you feel that your abdomen is tight?

Blood group of father & mother

MGOS

General Hx: Liver disease and blood thinner

Based on the history, what is the most important clue for your diagnosis?

Contractions that don't stop (and may follow one another so rapidly as to seem continuous)

Pain in the uterus

Tenderness in the abdomen

Vaginal bleeding

Uterus may be disproportionately enlarged

HTN/Tachycardia/Fetal distress

Admission Orders: DAVID

Diet: NPO

Activity: as tolerated

Vital signs every 2 hours

IV: D5 h NS +20 meq KCL@100 CC /h

Investigations:

CBC, partial thromboplastin time (PTT), INR, fibrinogen assay, fibrin degradation produce (FDP)

D-dimers, lytes, Creatinine

Type and Scree (4 cross-matched Packed Red blood Cell)

Intensive Care Unit (ICU) consultation

Neonatal ICU consultation

Oxygen at 10 L /minute by non-rebreather mask

Insert indwelling Foley catheter

Strict hourly intake and output

Anesthesia Consult

Begin continuous external fetal monitoring for the fetal heart rate and contractions

If the patient is hemodynamically unstable after fluid resuscitation begin a transfusion. Correct coagulopathy, if present.

Administer Rh immune globulin if the patient is Rh-negative

Treatment depends on the amount of blood loss and the status of the fetus.

If the fetus is less than 36 weeks and neither mother nor fetus is in any distress, then they may simply be monitored in hospital until a change in condition or fetal maturity whichever comes first.

Immediate delivery of the fetus may be indicated if the fetus is mature or if the fetus or mother is in distress.

Blood volume replacement to maintain blood pressure and blood plasma replacement to maintain fibrinogen levels may be needed.

Vaginal birth is usually preferred over caesarean section unless there is fetal distress.

Caesarean section is contraindicated in cases of disseminated intravascular coagulation.

Patient should be monitored for 7 days for PPH. Excessive bleeding from uterus may necessitate hysterectomy if family size is completed.

Case 7 (AUB cancer)

60y complains of bloody discharge. Take a focused history.

OCD

COCAB+ severity

Atrophic vaginitis: vaginal itching, dryness, pain during intercourse, hot flashes, mood changes, urinary frequency

Endometrial cancer:

Are you overweight?

Have you ever been pregnant (nulliparity)?

Do you have excessive hair on your body (PCOS?) Have you noticed any recent weight gain?

Do you have high BP?

hx of breast cancer?

Do you take Tamoxifen?

Cervical cancer

How many partners do you have?

Do you practice safe sex (use condoms)?

Do you have any history of STDs? Does your partner have any history of STDs? Smoking

Financial problems

Trauma, sexual abuse

Bleeding Tendency (Do you bleed excessively from your nose? Do you have any bruises on your body?)

Liver Disease: any liver disease

MGOS

General Hx: FHx of uterine cancer, breast cancer and cervical cancer

Name one investigation you would do: Endometrial biopsy

Case 8 (Endometriosis)

25y has vaginal bleeding and cramping & has missed University. Take a focused history.

OCD + COCAB+ Severity

Endometriosis:

How long does it last?

Pain with sex

Pain in the back

Pain with bowel movement

Trauma, sexual abuse

Bleeding tendency

MGOS

General Hx

family Hx of bleeding

HEADSSS (if <18)

Name 1 investigation:

Laparoscopy

Treatment: OCP

Diagnosis: Endometriosis

Case 9 (DUB)

40y has repeated irregular vaginal bleeding and spotting (OR disturbed menstrual cycles). Take a focused history.

OCD

COCAB+ Severity

MGOS : Menstrual Hx ---------> IN DETAILS + Relation of the bleeding to the cycles?

Menopausal symptoms (could be premature ovarian failure)

Endometriosis Qs:

PCOS as:

Endometrial cancer Qs:

Cervical cancer Qs:

Pituitary gland Qs:

Thyroid Qs

Trauma, sexual abuse

Bleeding tendency Qs:

Any medical condition should I know about?

Any investigations done before? . ----> YES, I had: U/s and CBC

General Hx: family Hx of bleeding, Drugs

The U/S: showed bulky uterus and normal ovaries and the CBC: showed anemia what is your diagnosis?

Dysfunctional Uterine bleeding (DUB) (Diagnosis of Exclusion(So everything is negative ) Investigations:

CBC, serum ferritin, coagulation profile

ß-hCG, prolactin, FSH, LH, serum androgens, Day 21 progesterone to confirm ovulation.

TSH, T3, T4

Pap test

Pelvic O/S: detect polyps, fibroids; measure endometrial thickness

HSG: very sensitive for intrauterine pathology (polyps, submucous fibroids)

Endometrial biopsy: consider biopsy in women >40 yr

D&C: not for treatment; diagnosis only (usually with hysteroscopy)

Treatment:

1) Medical

a.Mild DUB:

NSAiDs

Anti-fibrinolytic (e.g. CyklokapronR)

Combined OCP

Mirena IUD

Danazol

b.Acute severe DUB:

Replace fluid losses, consider admission e Premarin: 25mg IV q4h + Gravol Tab. 50mg PO q4h.

PLUS: Ovral Tab PO tid till bleeding stops (24hrs), then bid for 2 days, then od for 3days.

Continue conventional OCPs if pregnancy not desired.

Clomiphene citrate: in patients who are anovulatory and who wish to get pregnant. 2) Surgical

Endometrial ablation

If done with childbearing: hysterectomy is definitive treatment

DD of bulky Uterus by U/S:

Adenomyosis

Fibroids

Pregnancy

Hydatidiform mole

Uterine carcinoma

Imperforate hymen leading to hematometra and pyometra

Extra Reading

Dysfunctional Uterine Bleeding: Abnormal bleeding not attributable to organic (anatomic/systemic) disease. DUB is a diagnosis of exclusion. Anovulatory AUB often used synonymously with DUB.

Case 9

40y pain her right lower quadrant that radiates to her shoulder. Hx and Physical

C/O : Abdominal pain & vaginal bleeding.

OCD

Pain analysis

COCA B + severity

Urinary symptoms

Appetite Nausea Vomiting

Last BM

Gallbladder stones

Pancreatic disease

Diarrhea

Constipation

Menstrual Hx:

Menstrual regularity: Yes, its regular

Last menstrual period: 5 weeks ago is it possible you're pregnant? I'm not sure

Pregnancy Hx:

Previous pregnancy: No

Any hx of abnormal pregnancy: risk factor

Previous hormonal use: risk factor

Abnormal shaped uterus: risk factor Gynecological Hx:

Hormonal treatment before: risk factor

Pap test

Dilatation/Curettage

IUD: risk factor Sexual Hx:

Sexually active

# Partners

STDs

Use of condoms

Hx of pelvic inflammatory disease: risk factor

General Questions:

Previous surgeries i.e. tubal ligation: risk factors

Diagnosis:

Ectopic pregnancy

Name 3 things that need to be done:

1.Vaginal exam

2.Beta HCG

3.Vaginal US

Differential Diagnoses:

Appendicitis, pelvic inflammatory disease, abortion, torsion of ovarian cyst

Investigations:

BHCG, trans-vaginal ultrasound, upright chest x-ray, urinalysis, CBC Next steps: Admit the patient, NPO, fluids, urgent obstetrics consultation

Case 10 (infertility)

32-year-old female complains of infertility. Take a history.

Have you ever been pregnant before?

How long have you been trying to get pregnant?

Endometriosis: pain with bowel movement, pain during intercourse, backache, irregular menstrual cycle

PCOS: excessive hair on your body, have you recently gained weight?

PID: have you ever had a STDs? How severe was that?

Pituitary adenoma: headache, blurred vision, breast discharge, change size of your hand,

Thyroid

Specific Qs

What about your partner? Does your partner have any children from previous relationships?

Has your partner had any previous surgeries?

Has he had a semen analysis?

How often do you have sexual intercourse?

Menstrual Hx

Gynecological Hx: any previous interventions such as D and C for Asherman's syndrome?

Obstetric Hx

Sexual Hx: any previous STDs

General Hx

Single investigation

Hysterosalpingogram: Done 8-10 days after Ist day of menstruation

Name additional investigations:

TSH, PRL, FSH, LH, BHCG, semen analysis, investigation for PCOS



Case 11 (Pap smears counseling)

17y would like some information about Pap smears.

3 Questions of Counseling

I can provide you with information about Pap smears. Firstly, I'd like to start off by asking you some questions to get an overall idea of your health.

Some of the questions are intimate, so t assure you that all the information we discuss will remain confidential, unless I have your permission to disclose it, or unless I'm required to report it by law.

What raised your concerns about Pap smears?

How much do you know? How much would you like to know?

Sexual Hx

Gynecological Hx

Menstrual Hx

Obstetric Hx: Have you ever been pregnant?

General Hx: smoking hx, must ask about Fhx of Cervical cancer

Social Hx: low socioeconomic status is a risk factor

HEAADSS

Counseling

The Pap smear is a screening test that looks for cancers and pre-cancers in the cervix. Pre-cancers are cell changes that might become cancer if they are not treated the right way. A Pap test can save your life.

It can find early signs of cervical cancer. If caught early, the chance of successful treatment of cervical cancer is very high.

In the past, we used to screen every 3 years after being sexual active or at the age of 21 years. Now, we start screening at the age of 21 years.

These pre-cancer cells could take 8-10 years before developing malignancy. The earlier we detect these changes, the sooner we can deal with them.

Cervical cancer can be caused by HPV infections. Fortunately, there's a vaccine for it, The HPV vaccine is given in 3 doses between the ages of 9 to 26 years.

Let me draw you a diagram about the procedure.

We take a piece of tissue from the cervix and from the uterus. If pt asks "Is it painful?", respond, "it's tolerable".

We are going to examine the cells under a microscope. This test is done every year, but if we see that all your consecutive tests are normal, we can repeat it every 3 years until the age of 65.

If we find any changes that raise our suspicion, we can repeat our test after 3-6 months or request for a colposcopy.

Do you know what a colposcopy is?

A colposcopy helps us to magnify your cervix. We put a fluid called acetic acid to detect any lesions. if we see anything abnormal, we take a biopsy.

If the biopsy result is positive, we can remove the lesion by laser or by freezing or by electricity using the loop.

If you don't want to be pregnant, we also have the option of removing your uterus by a hysterectomy.

I will give you a pamphlet to take home about Pap smear.

Do you have any question?

Pt: Can we do the Pap test today? If she is 21 year old

Dr: Yes, if you're not menstruating.

Pt: Can I bring my boyfriend with me?

Dr: Yes (In the case of a Mammography, say no, as it will expose him to radiation)



Case 12 (Pap smears)

37y Pap test results indicate CIN 3. Suggest a colposcopy.

1.Inform her of the results

2.Evaluate her risk factors

3.Make a management plan

I received your test results & we found some abnormalities. The good news is that the cells are not cancerous.

The Pap smear is a screening test that looks for cancers and pre-cancers in the cervix. It takes abnormal cells around 8-10 years to develop cervical cancer.

Cervical cancer can be caused by HPV infections. Fortunately, there's a vaccine for it. The HPV vaccine is given in 3 doses between the ages of 11 to 26 years. Let me draw you a diagram about the procedure.

In your case, we will do a colposcopy.

We take a piece of tissue from the cervix and from the uterus. If pt asks "Is it painful?" respond, "it's tolerable".

We are going to examine the cells under a microscope.

I'd like to ask you a few questions to determine your risk for cervical cancer. Sexual Hx: How long have you been sexually active?

Do you practice safe sex, do you have multiple sexual partners, STDS, vaginal discharge smoking, HPV, social Hx, family Hx

Let me ask you more questions to evaluate your general health

Menstrual Hx Gynecological Hx Pregnancy Hx

General Questions

Now let's get back to your management plan. ? A colposcopy helps us to magnify your cervix. We put a fluid called acetic acid to detect any lesions.

If we see anything abnormal, we take a biopsy. If the biopsy result is positive, we can remove the lesion by laser or by freezing or by electricity using the loop.

If you don't want to be pregnant, we also have the option of removing your uterus by a hysterectomy.

I will give you a pamphlet to take home about Pap smears.

Do you have any questions? If the patient is a smoker or has multiple partners counsel

Case 13 (Preeclampsia)

1-23-year-old Dorris Moorehouse's blood pressure was high when she tested it at the pharmacy (BP 140/95).

She is 32 weeks pregnant. Address this issue and make a management plan.

2-May also be: Pregnant patient moved from Ottawa to Montreal and is looking for an obstetrician.

3-Pregnant patient had protein in her urine.

Physician: How may I help you?

Patient: i measured my blood pressure at the pharmacy and it was high.

Physician: Why did you decide to measure your blood pressure?

Patient: I just did it for fun.

Physician: As I can understand, you are pregnant, Congratulations! (Start from here if looking for obstetrician or protein in urine)

How do you feel about this pregnancy?

Is this your first pregnancy?

Do you recall your blood pressure reading in the first half of your pregnancy?

Have you done all the necessary tests while pregnant?

Have you had an ultrasound while pregnant?

Is it possible that there may be an abnormality with your baby?

Have you had multiple pregnancies?

Do you have a history of high blood pressure, blood sugar, or kidney disease?

FHx of high B.P in the family.

Do you suffer from headaches, blurring of vision, bleeding, abdominal pain, liver disease, weight gain, swelling of the face, any abnormal movement, bruises, yellow discouloration, weakness or loss of sensation

Pregnancy Questions: movement of the baby, contractions, broken water, vaginal bleeding

MGOS

General Hx

Social Hx

Counseling

Preeclampsia is a serious condition that affects about 5 percent of pregnant women and typically starts after 20 weeks of pregnancy.

Elevated blood pressure is the primary symptom, but there may be others such as protein in the urine, liver or kidney abnormalities, persistent headaches, or vision changes.

The condition most commonly shows up after you’ve reached 37 weeks, but it can develop any time in the second half of pregnancy, including during labor or even after delivery (usually in the first 48 hours).

There's evidence that changes in blood flow to the placenta may trigger the release of high levels of certain placental proteins into your bloodstream

Risk factors:

Chronic hypertension

Certain blood clotting disorders, diabetes, kidney disease, or an autoimmune disease such as lupus

Having a close relative (a mother, sister, grandmother, or aunt, for example) who had preeclampsia

Being overweight (having a body mass index of 26 or more)

Carrying two or more babies

Being older than 40 years

History of preeclampsia. A personal or family history of preeclampsia increases your risk of developing the conditions

First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy.

Complications of preeclampsia

Slow growth, low birth weight, preterm birth and breathing difficulties for your baby. Placental abruption in which the placenta separates from the inner wall of your uterus before delivery which might cause heavy bleeding which can be life-threatening for both you and your baby.

HELLP syndrome which stands for hemolysis (the destruction of red blood cells), elevated liver enzymes and low platelet count — syndrome can rapidly become life-threatening for both you and your baby. Symptoms of HELLP syndrome include nausea and vomiting, headache, and upper right abdominal pain. HELLP syndrome is particularly dangerous because it can occur before signs or symptoms of preeclampsia appear.

Eclampsia. When preeclampsia isn't controlled, which is essentially preeclampsia plus seizures — can develop. If Left untreated, eclampsia can cause coma, brain damage and death for both you and your____

Cardiovascular disease. Having preeclampsia may increase your risk of future cardiovascular disease

Management plan: This is my plan!!!!

1.We need to keep you in the hospital under observation.

2.I am going to examine you.

Take a serial measurement of your B.P, measure your weight, observe your mental status, & examine your reflexes. I'd like to conduct a follow-up of your fetal movement. Do a urine test to measure protein over 24hrs.

3.You should have bed rest, consume a normal diet, normal salt. At this point, you don't need any medication (depending on BP reading)

4.Our aim is to continue this pregnancy up to 37 weeks, if possible.

As you're not at 37 weeks yet, your condition is mild and appears stable. Your baby's in good condition, you probably won't need to deliver right away. Instead, you might be sent home and told to take it easy. (You may be asked to monitor your blood pressure at home or have a nurse check on you.)

Do you jive near the hospital? We'll need you to come in for regular visits. If we are able to control your symptoms now, you can come in for regular visits at 37 weeks of pregnancy.

5.If you have any alarming signs such as rapid weight gain, visual disturbances, seizures, or abdominal pain, you must go to the emergency room right away.

6. You have to know that the definite treatment is always delivery and your B.P should return back to normal after 2 weeks.

7.If you have mild preeclampsia and you're at 37 weeks or more, you'll likely be induced, especially if your cervix is starting to thin out and dilate. If there are any signs that you, or your baby, won't be able to tolerate labor, you'll have a Cesarean-section.

8.If you're diagnosed with severe preec'ampsia, you]' definitely have to spend the rest of your pregnancy in the hospital. You may be transferred to a hospital where a high-risk pregnancy specialist can care for you. In that case, yoWll be given magnesium sulfate intravenously to prevent seizures, as well as medication to lower your blood pressure, if it's extremely high.

Patient: Can I go on a business trip?

Physician: No, this is a serious condition that may affect both you and your baby.

Patient: Can I pick up my daughter from daycare?

Physician: No, I do not suggest that. Do you have a relative or friend to call that can help you out.

if the patient responds "no" I'll speak to a social worker to help you find a solution

If patient doesn't want the treatment ,Fill in a 'Refusal of Treatment' form

Additional Reading: The Diagnostic Criteria for Preeclampsia

Preeclampsia

Blood pressure: 2140 mm Hg systolic or 90 mm Hg Diastolic after 20 weeks of gestation, in a woman with previously normal blood pregsure Proteinuria: 0.3 g of protein in a 24„hour urine collection (usually corresponds with 1+ or greater on a urine dipstick test)

Severe Preeclampsia

Blood pressure: 2160 mm Hg systolic or 110 mm Hg diastolic on 2 occasions at least 6 hours apart in a woman on bed rest

Proteinuria: 25 g of protein in a 24-hour urine collection or 3+ or greater on urine dipstick testing of 2 random urine samples, collected at least 4 hours apart

Antihypertensive Drugs Commonly Used in the Treatment of Severe Preeclampsia

Hydralazine (Apresoline) o Initial dose: 5 mg IV or 10 mg 1M

When blood pressure is controlled, repeat initial dose as needed (usually about every 3 hours; maximum, 400 mg per day),

If blood pressure is not controlled in 20 minutes, repeat the initial dose every 20 minutes until the maximum dosage is reached, or go immediately to next step.

If blood pressure is not controlled with a total of 20 mg IV or 30 mg 1M, consider using a different antihypertensive drug (labetalol, nifedipine [Procardia], sodium nitroprusside [Nitropress]).

Labetalol (Normodyne, Trandate)* o Initial dose: 20 mg in IV bolus If blood pressure is not controlled, give 40 mg 10 minutes after initial dose, and then 80 mg every 10 minutes for two additional doses (maximum: 220 mg).

If blood pressure is not controlled, use a different antihypertensive drug (hydralazine, nifedipine, sodium nitroprusside



Case 15 (PID)

19-year-old Sara Anderson has vaginal discharge. Take a history in 5 mins.

OCD

COCAB

Do you have vaginal irritation?

Is it related to your menstruation?

When was your last menstrual period?

Is it possible you may be pregnant?

Do you take any hormonal treatment?

Do you use any chemical for vaginal douches?

Are you sexually active?

Associated symptoms

Do you have a sore throat?

Do you have joint pain, skin rash, eye discharge, or abdominal pain?

Fever

Menstrual Hx Gynecological Hx

Obstetric Hx

Sexual Hx

HEAADSS. (If less than 18)

Bacterial Vaginosis is diagnosed when at least 3 of the following 4 are present (Amsel criteria):

L Thin, watery, grey discharge

3.Fishy odor with 10% KOH (called a whiff-amine test)

4.Vaginal epithelial cells coated with bacilli (clue cells)

A vaginal culture is not necessary for diagnosing BV or candidiasis; clinical signs and symptoms alone are sufficient.

Counseling:

Having had bacterial vaginosis does not protect a person from getting it again. A woman may have it many times in her life.

If a woman has repeat infections in a short period of time, she may have transmitted the bacteria to her sexual partner, who is passing it back to her. Treatment of the partner with the same antibiotics should resolve the problem if symptomatic. Since the bacteria that causes bacterial vaginosis is naturally occurring, prevention is aimed at the factors that induce an overgrowth.

Wear cotton, not nylon, underwear. Avoid douching, feminine hygiene sprays, and scented tampons and maxi-pads. Take bubble baths in moderation.

Wipe from front to back, not back to front after going to the bathroom.

It is not reportable to public health. There is no evidence that treatment of partner is necessary unless they have symptoms

NB: Please read associate manual for STDs, only PID, Candida, trichomonas, bacterial vaginosis

Case 17 (Atrophic Vaginitis)

73-year old female presents with vulvar irritation & itching. Take a history within 10 minutes. After the history taking, the examiner will show you a physical exam, and you must explain the findings and appropriate management to the patient.

OCD: vulvar irritation (patient feels embarrassed)

Menopausal symptoms: pain during intercourse (no other symptoms)

Obstetric/sexual history/general questions

Diagnosis: Atrophic Vaginitis

Patients will have dryness, itching, discharge, pain during intercourse & feel pressure.

The examiner will provide a photo of a red vagina, and state that it is atrophic vaginitis

Explain the findings:

The symptoms you are feeling are a result of the hormonal changes that occur during the menopause

Normal physiology of the body

I will give you vaginal cream

Patient: Are you sure it's only due to menopause?

The symptoms you're describing are most often related to either estrogen deficit or a yeast infection such Candida may also cause a bright red, well demarcated rash, or with a thick cottage cheese-like exudate.

Cancer is still one of the possibilities, I will examine you, I will send for investigation to rule out other causes. If needed, we may take a biopsy.

Case 18 HRT

52-vear-old Sara Anderson would like some information on HRT. Counsel this patient.

3 questions of counseling

OCD (Hot flashes or vaginal dryness)

Symptoms of Menopause

Weight changes ......increased wt.

Bone pain

Sweating

Feel heart racing

Urinary frequency

Do you control your urine..she has incontinence

Vaginal dryness and irritation....yes

Pain during sexual intercourse

Sleep disturbances

Mood swings

Fracture (Osteoporosis) How is your sexual desire? ----decreased desire

Contre indications

History of liver disease (liver disease)

History of breast cancer and family history of breast cancer (Breast cancer)

History of Uterine cancer (Uterine cancer)

History of clot in legs (DVT)

History of chest pain and stroke (atherosclerotic disease)

Migraine

Abnormal vaginal bleeding

Does heat and cold bother you more than others (hyperthyroidism for hot flashes?)

How is your diet? Do you drink milk? Do you do exercise regularly? Menstrual Hx

Gynecological Hx: Ask about Mammography

Obstetric Hx

Sexual Hx

General Hx: smoking hx

Fhx of uterine and breast cancer and Osteoporosis (bone disease)

I will give you vaginal cream for vaginal dryness.

You have to drink milk

The patient will respond "l don't like milk" In that case, I'll prescribe you some calcium and vitamin D tablets

You should exercise regularly.

I suggest you stop smoking, as it increases your chances of heart disease.

if the bleeding continues after 8 months, come to my clinic for further investigations.

Do you have any questions?

Commitment to the plan: Are you willing to try what we've discussed?

Case 19 HRT

52y is here to ask you about hormonal replacement therapy. Please take a history and address her concern.

Positive in case:

-Irregular periods for about 8 months, I-MP 3 months ago

-History Of H TN for 12 yrs and takes thiazides

-Borderline cholesterol

-Positive family history of breast cancer in her mom and her aunt. - Vaginal dryness and hot flashes that "are driving her husband crazy"

-She does not sleep well because of hot flashes.

Patient's concern:

I've heard it HRT causes breast cancer. Do you think I should take it for my hot flashes?

Counseling:

There has been much controversy surrounding the relationship between HRT use and breast cancer.

WOMEN'S HEALTH INITIATIVE (WHI) is the largest study conducted on 16,608 women with an intact uterus investigating health risks and benefits of HRT in healthy postmenopausal women 50-79 years old showed increased risks of invasive breast cancer (8 additional cases with combined HRT per 10,000 women each year).

However, some other studies did not show this effect. As I can see you have some risk factors that makes me concerned about giving you HRT (family history of breast cancer and H TN), so how do you feel about giving you different medication and see if it would be helpful?

Except HRT, what other "prescription" medication would you give her?

For hot flushes:

clonidine, SSRI, Effexor, gabapentin, propranolol

For vaginal atrophy:

Local estrogen- cream (Premarin), vaginal suppository (VagiFem), ring (Estring), lubricants What examinations would you do before you order HRT?

Complete Physical exam (Pelvic and breast exam)

Pap smear Mammography

Lipid profile



Case 20 (Amenorrhea)

23y hasn't had her period in 6 months. Take a focused history.

OCD:

How did it start? Did this happen all of a sudden or gradually?

When did it start

Is this the first time?

Does it come and go

Have you noticed any changes in your weight (PCOS)?

Have you noticed any abnormal hair distribution (PCOS)?

Acne How's your sexual desire (PCOS)?

Do you have high blood sugar?

Does heat and cold bother you more than others (Thyroid)?

Headache, blurring vision, nipple discharge, t size of feet (Pituitary)

Do you have any stress in your life, have you changed your diet, history of psychiatric disease, exercise

(Anorexia Nervosa)

Hot flashes, backache, bony pain, mood changes (Premature ovarian failure)

Menstrual Hx: LMP, is it possible that you may be pregnant?

MGOS

Gynecological Hx: Dilatation and curettage (Asherman's)

Med Hx (Anti Psychotic Meds)

Investigations

BHCG TSH, PRI LH/FSH ratio DHEAS MRI

Case 21 (Amenorrhea)

A 30-year-old female comes in due to a 7-month history of amenorrhea. She's never been pregnant. Take a focused history

On questioning you discover:

Menstrual Hx: Age of menarche is 14 years, 60-80 days between cycles and her menses lasts 8-10 days, with a profuse hemorrhage.

She did a urine dipstick test 6 weeks ago and another one this morning, she is not pregnant.

She states she has t facial and chest hair, and has recently developed acne.

Medications: she takes "Materna" because she is trying to get pregnant for the past 2 years, No investigations done for her infertility yet.

List the 3 most likely causes of her current amenorrhea:

1.PCOS

2.Androgen producing tumor

3.Adrenal tumor

What investigations would you request?

BHCG TSH, PRI LH/FSH ratio DHEAS Ultra sound MRI

What health care and preventive measures would you recommend to this patient?

Reduce weight

Control blood sugar

If she does NOT want to get pregnant, what you prescribe?

Lifestyle modification BMI, ++ exercise)

OCP monthly to prevent endometrial hyperplasia due to unopposed estrogen

Hirsutism: mechanical removal of hair, Anti androgens ( finasteride, flutamide , spironolactone)

Oral hypoglycemic (e.g. metformin) if type Il diabetic

Tranexamic acid (Cyklokapron@) for menorrhagia only

WIG

If she wants to get pregnant, what you prescribe?

Medical induction of ovulation:

Clomiphene citrate, human menopausal gonadotropins (Pergonal), LHRH, recombinant FSH, and metformin Ovarian drilling (perforate the stroma), wedge resection of the ovary Bromocriptine (if hyperprolactinemia)

Case 22

25 years old Charlotte Brown delivered a 3.0 kg baby four months back. She lost obstetrical follow up at 6 weeks. She is now in the clinic (Do not ask about baby). Take relevant history from mother.

C/O: (l am feeling tired)

OCD: (Of Fatigue)

How did it start? Did this happen all of a sudden or gradually?

When did it start? ----> 3 months after my delivery

Is this the first time? Does it come and go?

Menstrual Hx:

--> Did not have menses since my delivery 4 months ago

Is it possible that you may be pregnant? ---> not sure (no tests done)

sx of early pregnancy Qs?all +Ve

Gynecological Hx:

Sexual Hx: sexually active with her husband, no use of contraception (Only withdrawal)

Obstetric Hx:

DID:

1)PPA:

Pregnancy: already asked

Sheehan's Syndrome: Any heavy bleeding during or after delivery?

Lactational amenorrhea: Do you still breastfeed your baby? No, I stopped 1 month ago . Why? ----> I felt tired-

2)Fatigue pathway DID:

All are —ve except for Thyroid

She had Hypothyroidism, stopped medication (Levothyroxin) and lost medical follow up.

3)Other general causes of Amenorrhea:

•Any change in your wt.? , any acne? Abnormal hair distribution? (PCOS)

•Headache, blurring vision, nipple discharge, t size of feet (Pituitary)

•Do you have any stress in your life?, have you changed your diet, history of psychiatric disease, exercise? (Anorexia Nervosa)

•Hot flashes, backache, bony pain, mood changes (Premature ovarian failure)

General Hx: Medication (anti-psychotics)

*What one investigation will you order for this lady?

•B-HCG

Case 23 (Abortion)

19y would like to have an abortion. Counsel her.

•Assure confidentiality

•Would you like anyone to be present during our discussion?

•How do you feel about this pregnancy?

•How did you come to know that you're pregnant?

•When was your last menstrual period (How many weeks?)

•Was this a planned pregnancy? Have you been sexually abused?

•Ask for signs of pregnancy

MGOS

Do you have chest pain, kidney disease, liver disease?

Known or suspected ectopic pregnancy: any US done, back pain, history of abnormal pregnancy

On long-term corticosteroid therapy (including those with severe, uncontrolled asthma)

Bleeding tendency

Severe anemia

Pre-existing heart disease or cardiovascular risk factors (e.g. hypertension and smoking)

How's your mood? Do you feel down?

Ml PASS ECG (as sleep and concentration can affect a patient's decision)

Do you have any thoughts of hurting yourself?

What was your partner's reaction?

How do you feel about your partner?

Have you shared this decision with your family?

Why do you want an abortion?

General Hx

HEAADDSS if <18 years

Counseling:

Abortion is the irreversible termination of your current pregnancy.

it is your choice as well as your right. It's legal in Canada. For some women, the decision is relatively easy to make, for others it is more difficult.

We've seen many patients feeling guilty after the abortion. This choice will be respected by all the staff at the Women's Clinic. You will be treated with kindness, understanding and competence.

Our role is to get an abortion in the best possible conditions, in medical terms and human terms. All your efforts will remain confidential.

We sometimes have to do it if pregnancy associated with a risk to the health of the mother of if there is serious abnormality in your baby.

Do you know if you continue your pregnancy, after birth, you can give your baby to government to take care of without responsibility on you.

If you have any financial problem, I can send you to a social worker and government could help you. The gestational age limit after which many practitioners will not perform an elective abortion in Canada is 20 weeks; your decision should be made sooner, before 16 weeks would be best

Its one day procedure must be before 20 weeks of pregnancy. As you are ---------weeks pregnant (depending upon weeks of pregnancy)

we can do D/C. We ask all our customers to come to the clinic before the day of abortion for a preparatory meeting and opening the file.

During this first visit, you meet a nurse who completes your medical record, is a blood test to determine your blood type, and an ultrasound (which witl be read later by the doctor).

The nurse will see you first single. In a second step, if you wish, the person who accompanies you may attend part of the meeting.

This first visit lasts about 45 minutes. You will have the opportunity to discuss contraception and ask him the questions that concern you

You will receive two intravenous drugs, painkillers and relaxants drugs

The procedure takes about ten minutes under local anesthesia

It is possible that you feel cramps, menstrual cramps. They will be short-lived, and soon relieved by medication

If your blood group is negative type, a drug will be administered in order to avoid problems in future pregnancies.

Is it dangerous?

Complications around abortion are very rare, and usually easy to treat.

In order of frequency:

Infection: despite all precautions, some women spontaneously develop an infection of internal organs (uterus, fallopian tubes).

If you have any of the signs of infection (fever, pain, foul-smelling discharge), consult your doctor immediately.

Infection treated with antibiotics in the early stages usually without sequelae.

Hemorrhage during surgery, it is unlikely with the suction method. In addition, we have drugs to stop abnormal bleeding quickly.

In the coming days, if you have any signs of bleeding, immediately consult a hospital.

There is no need to panic, because despite appearances blood loss is minimal, but it must be stopped (either by drugs or by another curettage), Damage to the uterus: rare, and usually without serious consequences. This complication may require observation in hospital.

Healing is most often done spontaneously without surgery.

Risk of infertility: an untreated complication could cause a fertility problem .But today, the risk is almost zero.

If you decided to continue your pregnancy (advice for antenatal care) but if you want to do abortion, we will do it. You are informed of these risks for legal reasons, to sign an informed consent, as with any medical intervention. I would like to see you after the procedure to put a plan for contraception and to discuss your feeling.

Readings:

Medical:

< 9 weeks: Methotrexate + Misoprostol

> 12 weeks: Prostaglandins (intra or extra amniotic) + misoprostol

Surgical:

< 12-16 weeks: dilation + curettage e > 16 weeks: dilation + evacuation

Contraindications

Absolute contraindications are virtually unknown.

If abortion presents a medical risk to the patient, then continuation of the pregnancy presents an even greater risk.

The type and timing of an abortion procedure or method may be contraindicated based on the medical, surgical, or psychiatric condition of the patient.

Medical abortion is contraindicated in patients with clotting disorders, severe liver disease, renal disease, cardiac disease, and chronic steroid use.

Medical abortion is also contraindicated in women with no access to emergency services and no partners or family to be with the patient during the heaviest bleeding times.

Surgical abortion is contraindicated in patients with hemodynamic instability, profound anemia, and/or profound thrombocytopenia.

The conditions should be managed and the context of pregnancy continuation must be considered.

The rare instance of placenta accreta and percreta in the second trimester may necessitate laparotomy with hysterotomy or hysterectomy.

Previous uterine incisions, including cesarean deliveries or multiple cesarean deliveries have been regarded as a contraindication to medical protocols, but some recent literature has suggested this may be safe.

Case 24 (incontinence)

70y urinary incontinence. Take a focused history.

I am your doctor; I'd like to assure you that everything we discuss will be kept confidential.

OCD

Types of incontinence:

Total: do you suffer from continuous dribbling of urine

Stress: do you lose some drops while coughing or sneezing

Urge incontinence: do you sometimes have an intense desire to pee and lose some drops of urine before reaching the washroom?

Do you use pads? How many?

How does that affect your life? That must be very hard for you.

Menstrual history (2 questions)

Menopausal symptoms (all)

Gynecologic history

Pregnancy history (how many, mode of delivery, any complications)

Sexual history/vaginal discharge

Urinary symptoms

Irritative symptoms

Do you go to washroom more than usual? (frequency)

Do you have an intense desire to urinate? (urgency)

Does it take you longer to start peeing? (hesitancy)

How many times you wake up at night to pee? (Nocturia)

UT l: fever, burning of urine

Stones: blood in urine, history of stone passages

Other factors:

Stroke: weakness, loss of sensation, difficulty speaking

Parkinsonism: tremors, difficulty in walking

DM; pee more, drink more

Constipation

Stress

Alzheimer's: Memory loss

General: DM, surgery, medication such as diuretics, coffee

Investigations:

1.Urine analysis

2.Urine Culture

3.Abdominal and pelvic US

4.Urodynamics

Case 25 (CS)

A pregnant patient would like to have a planned elective Cesarean section. Counsel her in 10 minutes.

3 questions of counseling

How do you feel about this pregnancy?

Why do you want a CS?

Have you shared this decision with your partner?

How's your mood?

Indications

Do you have heart disease?

Are you regularly followed up by a doctor?

Have you had an ultrasound?

ts it possible you may have diabetes?

Twins

Abnormality in baby

Abnormality in the placenta

Abnormalities in your pelvis

Previous Cesarean section

Herpes infection

Pregnancy history: Have you been pregnant before? Is it possible that you're pregnant now?

Sexual history

Gynecological history Menstrual history

General questions

Counseling

A Cesarean section is performed on the basis of an obstetrical or medical indication or at the request of the pregnant patient.

Physicians will commonly perform the operation at a scheduled time, rather than waiting for the onset of labor.

Such planned caesarean sections are performed for many reasons including:

History of previous caesarean section

Placenta previa

Abnormal presentations

Multiple pregnancies

Known obstructions of labor Medical conditions (such as heart disease)

The disadvantages of Cesarean sections include: Risk of adhesions that could block the normal passage of the egg (ovum) from the ovary to the uterus

May reduce future fertility

Chronic pelvic pain

Bowel obstruction

Maternal mortality is higher than that associated with vaginal birth

Longer recovery time

Operative complications such as lacerations and bleeding may occur

Risk of neonatal respiratory distress necessitating oxygen therapy is higher if delivery is by cesarean

Benefits of Cesarean section

May reduce the risk of urinary incontinence, which is a common postpartum problem

Avoidance of labour pain which can be avoided in vaginal delivery by using special type of anesthesia called epidural

The CS can be an important and life-saving procedure when done at the right time: such as in the case of when the baby is big, if the mother had active herpes infections on her genitals, or if the mother's placenta was not in good condition.

Also, we may have to consider a CS if you or the baby were to experience any problems prior to the delivery.

While pregnant, I suggest you: eat healthy diet, avoid smoking/second-hand some, & avoid alcohol.

Consult your physician prior to taking any medication. Come in for regular check-ups.

Do you have any questions?

How do you feel about that?

Case 26:

A lady that is 30 weeks pregnant needs a Cesarean section. Counsel her.

Her boyfriend left her. She's unemployed. Her mood is fine.

She's concerned that she'll be alone after the delivery.

Medical team

A special nurse will come help you at home

Social worker

Talk about the epidural: it's a fine needle









 

Counseling

1. I am glad that you came in so we can discuss your situation and address your concerns. hopefully we will be able to make a decision by the end of our session today.

2. What raised your concern?

3. How much do you know about this?

4.How much would you like to know?

5.Are you following me?

6.Summarize

7.Commitment to the plan: am I able to explain clearly? Are you willing to start?

Case 1:

Refusal of Treatment:

A 68-year-old male with DM was scheduled to have his limb amputated. The night before the operation, he refused the treatment. Counsel him.

3 questions of counseling

Physician: As I can understand, you were scheduled for an operation tomorrow and you've decided to cancel it.

May I ask why you decided to cancel it?

Patient: I don't want them to cut off my limb.

Physician: That must be really hard for you to accept.

How long have you been thinking about cancelling the surgery?

Have you discussed your decision with your family?

How do you usually cope with difficult situations?

How's your mood (MIPASSECG)?

How's your sleep?

Are you aware of the consequences of the canceling the surgery?

Patient: Yes, I'll die.

Physician: Yes, over time that will happen; however, your death won't be sudden. By not having the surgery, you place yourself at a greater risk of infection. The amount of dead tissue will increase and you will have a higher chance of losing a larger part of your body. This will lead to multiple hospital admissions.

Are you following me? Is this clear to you?

Do you know about artificial limbs?

Patient: No, not really. Can you tell me about them?

How much would you like to know?

Patient: Everything, I guess.

Physician: Nowadays, when someone loses his limb due to a trauma or for any other reason, they have the option of artificial limbs that are designed for their personal needs. With the advances in technology, they are able to lead a normal life with these limbs.

If you'd like, I could arrange a meeting with a specialist that deals with artificial limbs, as well as a social worker that can provide you with more information.

Physician: Have you considered any form of alternative medicine?

Patient: Yes, my friend told me about it. It is herbal medicine. Is it good?

Physician: I'm not an expert on herbal medicine, however if you give me the name of the treatment, I can look into it for you.

Physician: If you have a severe infection, you may require artificial support or resuscitation. You have the choice to decide to be resuscitated or not. Do you know what resuscitation means?

Patient: No, I don't.

Physician: How much would you like to know?

Patient: Everything, I guess.

Physician: In an emergency, if your heart and lungs stop working, we press on your chest to revive your heart. A tube is placed in your windpipe to revive your lungs. We would also give you medication to increase your blood pressure. You must consider your decision.

Physician: Do you know anything about advance directives/ substitute decision makers?

An advance directive is a written or verbal statement where the patient directs the medical team about the level of end-of-life care he/she would like provided in advance.

In the case that you are no longer able to make decisions of your own, a substitute decision maker is a person that will make medical decisions on your behalf.

I could arrange a family meeting where you could discuss your wishes. *State that the patient has the right to refuse treatment!

Physician: This must be a lot for you to take in. I can imagine it's overwhelming. I'd like you to take a couple of days to think about what we've discussed.

If you've changed your mind, we can reschedule your operation.

How do u feel about that?

Did u come here alone?

2. A 69-year-old patient with colon cancer refuses an operation. Counsel the patient.

3 questions of counseling

May I ask why you don't want the operation?

Are you aware of the consequences of refusing the operation?

How's your mood/sleep?

Have you discussed your decision with your family?

How do you usually cope with difficult situations?

Same questions as the previous case

Consequences of refusing the operation

Physician: Are you aware of what a colostomy is?

A colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall.

With the advances in medicine, many patients are able to live comfortably with this device.

If you'd like to learn more, I could arrange a meeting with a social worker and SPECIAL NURSE to provide you with more details. The SPECIAL NURSE can teach you about stoma care.

Are you following me?

Do you know anything about alternative medicine?

Do you know anything about DNR or artificial resuscitation?

Do you know anything about advance directives/substitute decision makers?

Continue as before

Case 2:

Refusal of Chemotherapy:

A 38-year-old female with Hodgkin lymphoma, she had a report of her case from her medical oncologist stating that she should start taking chemotherapy, also listing possible side effects and that her life expectancy without treatment is 6 months. She refused the treatment.

Counsel her and address her concerns.

The patient has excellent eye contact and interrupts a lot

Physician: Hello Mrs. . . I had a report from your medical oncologist regarding your condition which necessitates treatment with chemotherapy and as I can understand, you are refusing to take it. Patient: well Dr. I don't want to take it. It is my decision

Physician: I understand and by the way it is your right to refuse treatment but let me ask you some more questions, is that ok with you?

3 guestions of counseling

How long have you been thinking about cancelling your treatment?

Have you discussed your decision with your family?

Yes, they are supportive and my ex-husband will take care of my daughters.

How do you usually cope with difficult situations?

How's your mood (MIPASSECG)?

How's your sleep?

Physician: How much do you know about your Diagnosis?

Patient: everything but why don't you tell me again Dr. in case miss understood something

you have a type of cancer that we call ....., do you know what mean by cancer by the way?

Patient: No what do you mean?

Physician: Cancer basically means that our own cells starts to multiply in an abnormal way, causing the body systems to fail and if not treat can cause serious complication even death.

Physician: Are you aware of the consequences of not taking chemotherapy?

Patient: Yes, I'll die.

Physician: Yes, over time that will happen; however, your death won't be sudden. By not having the treatment, you place yourself at a greater risk of advanced cancer with metastasis and multiple organ involvement. This will lead to multiple hospital admissions. Are you following me? Is this clear to you?

Physician: May I ask, why you decided to cancel treatment with chemotherapy?

Patient: I am afraid from chemotherapy side effects, as I can't take blood to deal with such side effects as you know, also it well make me weak and too sick to care for my children.

Physician: Ohh, I am sorry to hear that. I want you to know that I understand your concern and it's a stressful and scary situation. May I ask how many kids you have?

Patient: 2 Daughters

Physician: may I ask how old are they and their names?

Patient: 4 and 8 and she gave 2 names

Physician: repeat the names then pause then say; now you said that you can't take blood products may I know why?

Patient: I'm a Jehovah's Witness

Physician: I understand and respect that

Physician: Do you know what the side effects of chemotherapy are?

Patient: Some, can you tell me.

Physician: Look at the report and list all the side effects written in the report. Now I know this seems scary but let me explain to you each one and how can we prevent and or treat it. Is that ok with you.

Before I do that I want you to know that there are specific protocols to care for patients with cancer and other concerns like having defective renal functions, bone marrow depression, low immunity ....etc,

when chemotherapy is the only treatment option, including: strict follow up, low dose therapy and early intervention with supportive treatment, these protocols may apply to you.

Now let's talk about the side effects

Infection that can be prevented and treated by giving a combination of antibiotics and this is given to all patient receiving chemotherapy.

2- Anemia and bone marrow depression this can be treated by medication such as Iron pills if mild and in sever cases we give blood transfusion, know that you are a Jehovah's Witness so we can use other treatments.

Physician: Do you know what the alternatives to blood transfusion are?

Patient: No, not really. Can you tell me about this?

How much would you like to know?

Patient: Everything, I guess.

you get bone marrow depression from chemotherapy, you can be given other medications and blood products to support you and not necessarily whole blood which you refuse.

So chemotherapy does not mean blood transfusion.

We can give you:

-Granulocytes and Granulocytes stimulating factors.

-Immune globulins

-Factor concentrates and Cryoprecipitated antihemophilic factor

-Albumin

-Platelets and Fresh frozen plasma

-Erythropoietin

Physician: Can you take any blood products like albumin?

Patient: No I can not

Also:

You can consider pre-deposited autologous blood or blood components, meaning that you donate blood for yourself for later use? How do you feel about that? ---> I believe it is a good idea

-You can take or refuse any of these products according to your believes

-If you'd like, I could arrange a meeting with a specialist (Hematologist) that can provide you with more information.

3-for fatigue we can give some medication, also we take to our social worker, she will make sure to connect you with the right government agencies that provide help for patient with your situation and provide someone to help care for them and their children. So you do not have to worry about your kids and be able to care for yourself and them. Is that something you would to explore.

Patient: Yes

Physician: excellent, I will ask our social worker to meet with you after we are done,

4-Hair loss. This side effect is temporary and we solve that problem by using wigs, did you know that they are made from 100% human hair. There is no medical treatment that is proven to prevent that. I will ask our social worker to explain this option to you as well

5-. Physician: Have you considered any form of alternative medicine?

Patient: No, I believe and trust in modern medicine.

Physician: Thank you, it is good that to trust your Dr, it is an important part of your treatment.

Physician: If you have a severe infection, you may require artificial support or resuscitation. You have the choice to decide to be resuscitated or not. Do you know what resuscitation means?

Patient: No Dr. I am not here for that.

Physician: Do you know anything about advance directives/ substitute decision makers?

Patient: No Dr. I am not here for that.

*State that the patient has the right to refuse treatment!

*Everything we discussed will be documented in your chart

Physician: This must be a lot for you to take in. I can imagine it's overwhelming. I'd like you to take a couple of days to think about what we've discussed. If you've changed your mind, we can reschedule your treatment.

I also suggest that you take to your loved ones about, as some people find it easier to talk to their loved one, some times their religious figures. If you like I can arrange a meeting with our psychiatrist that may help you.

How do you feel about that?

Do you have other concerns?

i wish you luck and please don't hesitate to contact me or any of our team members if you need any

Same if the patient refuses intubation.

Case 2:

An 80-year-old patient is suffering from respiratory distress. He was confused during his admission. After intubation and resuscitation, he is totally alert. His son 50-year-old has asked you not to resuscitate his father in the future. Assure confidentiality

3 questions of counseling

Physician: As I understand, you have asked that your father not be resuscitated in the future. I can imagine this is a very difficult time for you.

Do you know if your father has any advance directives?

In the past, did he express his wishes not to be resuscitated? Did you speak with him about this issue before?

Are you his substitute decision maker?

Did you see him in the morning? Was he alert?

Does he have any psychiatric disorder? How's his mood?

Have you shared this information with your family?

Are you following me?

How's your mood? How about your sleep?

MIPASSECG

This must be a lot to take in. We can arrange a family meeting,

How do you usually communicate with your father in stressful situations?

Are you fully aware of the consequences of this decision?

Patient's son: Yes, my father will die.

Physician: Yes, he will die slowly and it will be a painful death.

As long as your father is capable of making this decision, he should decide for himself.

Why don't you speak to him and discuss your concerns? It's possible that he may share the same point of view.

Do you know any thing about resuscitation?

In an emergency, if your father's heart and lungs were to stop working, we'd press on his chest to revive his heart. A tube would be placed in his windpipe to revive his lungs. We would also give him medication to increase his blood pressure.

State that competent people are treated like adults, and allowed to make their own medical decisions.

How do u feel about that? Do you have any questions?

A 70-year-old man has inoperable pancreatic cancer. His wife doesn't want you to tell him the truth.

Physician: Why don't you want me to tell him?

Patient's wife: I'm worried he'll be shocked and won't be able to handle the truth.

Physician: If he asks me about his situation, what should I say?

Patient's wife: Just lie to him

can imagine this is a very hard time for & you have his best interest in mind. Ethically, I can't keep this information away from him.

If he were to find out, he'd lose faith in our medical team.

Let me ask you some questions:

Does he have a history of mental illness/psychiatric condition?

Does he have advance directives or a substitute decision maker?

Has he expressed any of these wishes before?

How's your mood? How's your husband's mood?

Have you shared this information with your family?

Explain resuscitation

Advanced directives?

Your husband has the right to know about the reality of his condition to help him plan & complete any unfinished work.

We can ask him if he wants to know the details of his condition. If he doesn't want to know, we'll respect his wishes. However, if he does want to know, we'll ask him how much he'd like to know and offer the information according to his wishes. I assure you the information will be provide in an empathetic manner.

Are you following me?

I'm sorry. At this point, I can't promise you not to tell him.

Do you have any questions?

Breakin Bad News: Patient dia nosed with cancer. SPIKES

S: Setting interview

Thank you for coming in today.

P: Perception

How much information do you know?

l: Invitation

How much information would you like to know?

K: Knowledge

Well I have good news and bad news for you today. The bad news is that you have skin cancer, melanoma.

Patient: Are you sure?

Physician: Yes, our pathologist confirmed it.

The good news is that you have treatment options such as radiotherapy & chemotherapy that can help you live longer. These treatments have side effects such as: nausea, vomiting, alopecia and repeated infections.

E: Emotion

Wait for patient's response.

Physician: How's your mood?

Did you come here alone today?

Would you like me call a social worker for you?

S: Strategy

Explain the treatment options

40-year-old John Fernando would like to be tested for HIV. Take a history the patient.

3 questions of counseling

Have you been tested before?

This test is done to determine if you are HIV (+)

If you have the virus, it takes up to 10 years to develop AIDS. So, having HIV doesn't mean that you have AIDS.

I'd like to ask you some questions about your general health.

Are you sexually active? With men or women?

How many partners have you had in the past? If the patient has many partners counsel

Do you practice safe sex?

Do you know your partner's HIV status?

Have you had any STDs in the past?

How about your partner?

Have you ever had a blood transfusion?

Do you share needles? If the patient responds "yes" counsel

Have you ever been exposed to a person with HIV?

Screen for symptoms for HIV

Cough, SOB, fever, skin ulcer, loss of wt, any lump or bump, flu-like symptoms, diarrhea How's your mood? Do you feel down?

Before sending you for an HIV test, I need you to sign the consent form. If you don't want anybody to know about the test, it's your right; however, if the results come back positive, I'm legally obliged to inform public health. If it is negative, we will repeat the test after 6 months. Are you following me? Is that clear to you?

How do you feel about that?

Case 2: 40-year-old John Fernando is waiting to be seen by you. Inform him that his results have come back and he is HIV positive.

Physician: Thank you for coming in today.

Do you know anything about your HIV test?

How much information would you like to know?

I have some good news and bad news.

Unfortunately your results came back and you have HIV .

Patient: Are you sure?

Physician: I am sorry this must be a lot to take in. Can we continue?

The good news is that having the virus does not mean you have AIDS. It can take up to 10 yrs. to develop AIDS. Nowadays, there are a lot of medications available to control the symptoms of AIDs. The biggest risk is immunodeficiency. With this condition, your body will be less able to fight against infections.

Have you thought of a plan? Do you plan on telling your partner?

Patient: What do you think doctor?

Physician: Well, it helps to be honest with her. If she isn't infected, she has the right to be protected. If she has been infected, she has the right to get the necessary treatment and support. Do you agree with me?

As your physician, I am legally obliged to inform the public health department. They will tell your wife.

If the patient is unwilling to tell his partner, suggest that he can take a couple of days to think about his decision. Inform him that you'd be happy to set-up a family meeting.

How's your mood? Do you have any thoughts of hurting yourself?

Did you come here alone?

Do you want me to call a social worker?

Counsel for safe sex

'Do not donate blood

Patient: Is it possible the results are wrong?

No, we run 2 tests for confirmation.

35 years-old John Fernando came for checkup. Counsel him You are meeting a patient who is irritable, moving in the room, looks upset and frustrated

---> Hello Mr.Fernando, my name is I am your doctor and I am here to help you, I can see that you are a little bit anxious and looks frustrated, would you please have a seat so we can discuss about your situation

-Dr.: How can I help you?

Pt.: my wife tested HIV +ve and now I would like to be tested.

Dr.: I understand your frustration and I know that it is a difficult situation---------> He will calm down And to be able to able to help you and fully address your concern, I need to start off by asking some questions to evaluate you fully, is it OK with you?

-Assure confidentiality

-How much do you know about HIV and its testing? - How much would you like to know?

-Sexual History----------> no practice of safe sex - Have you ever had a blood transfusion?

-Do you do IV drugs? Do you share needles?

-Screen for symptoms for HIV

Cough, SOB, fever, skin ulcer, loss of wt, any lump or bump, flu-like symptoms, diarrhea, penile discharge How's your mood? Do you feel down?

-Have you done any screening for other sexually transmitted disease?

Counseling:

This test is done to determine if you are HIV (+ve),_ If you have the virus, it takes up to 10 years to develop AIDS. So, having HIV doesn't mean that you have AIDS. Before sending you for an HIV test, I need you to sign the consent form. If you don't want anybody to know about the test, it's your right; however, if the results come back positive, I'm legally obliged to inform public health. If it is negative, we will repeat the test after 6 months. Are you following me? Is that clear to you? How do you feel about that? Do not donate blood, Practice safe sex. We might send you for testing of other STD. Any other concerns?

Pt: how that transmitted?........worried about that his friends are going to know?

Dr. : It can be transmitted through sexual contact with infected individuals, IV drug abuse (sharing needles) and blood transfusion or contact with infected materials (like needles). - Regarding friends Assure confidentiality

What are your next steps?

-Consent for testing

-Arrange a meeting to inform him about results

-Test for other STD: Gonorrhea, Hepatitis B, C and Syphilis

-Repeat HIV test within 6 months if —ve

-Inform public health if +ve

-Post-exposure prophylaxis (PEP): PEP must begin within 72 hours of exposure and consists of 2-3 antiretroviral medications and must be taken for 28 days.

Recommended PEP regimens are: Tenofovir combined with either lamivudine (3TC) or emtricitabiné (FTC) as preferred backbone drugs and these are also the preferred drugs for treating HIV.

A 52-year-old male with lung cancer had a right pneumonectomy a few years ago. Three weeks agg., he had weakness on his left side. At the time you ordered a CT. The results came back & they show multiple brain metastases.

The patient wants to know everything about his results. He asked you about his chance for survival

& if there's a cure.

He'd like to travel to Europe with his wife after his retirement in 3 months.

He was a smoker for 25 years. He quit for 15 years, but started again after the pneumonectomy (1 pack per day). He'd like to know if the smoking is the reason he has cancer again. Thank you for coming in today. I have some good and bad news to share with you today. We received your CT results, & we found brain metastasis. The brain is the most frequent site of distant metastasis in patients with lung cancer.

However the good news is that brain radiation therapy can be used for the treatment of multiple brain metastases. This is the most frequently used therapy for brain metastases. In this treatment, radiation is delivered to the entire brain. Radiotherapy has been shown in research studies to extend life and improve the quality of life for those with symptoms. 30% to 40% of patients will achieve a complete reversal of symptoms while 75% to 85% of patients will experience some improvement or stabilization of their symptoms, especially headache and seizure. Motor loss (problems with walking, coordination, balance, etc.) is less successfully treated.

Immediate side effects of radiation can include memory loss, particularly verbal memory (remembering what someone said to you), extreme fatigue, temporary baldness, skin rash, inflammation of the outer ear, and hearing loss.

Advanced directives

DNR

Family meeting

How is your mood? Did you come alone?

Do you think it is related to smoking

It is too early to say if smoking caused the metastases. Let's concentrate on our next steps When the patient mentions travelling for Europe for many months:

I think it may be a good idea, but how about we start your treatment first, and see how its going. Does that work for you?

Case 3:

28-year-old Maria Jones comes to your office with vague complaints (headache, insomnia). She is injured with bruises on her head & arms. Her husband is in the room. Counsel Maria.

headache does not necessarily mean neurology (especially when there are bruises), think about spousal abuse! Insomnia does not always mean depression.

Be supportive, mention her name through out the conversation, but do not touch her.

Physician: Maria, can you let me know what happened?

Her husband will want to respond to your questions. He'll stat "she has a headache."

Physician: I really appreciate your help Mr. Jones. I'd like Maria to answer these questions for me.

If the husband persists Ask him to politely leave the room politely "Mr. Jones I see that you're concerned about your wife. Would you please have a seat outside while I examine Maria. I will call you back if I need any help."

Physician: Maria, what happened? Maria: I fell on the floor.

Physician: There are bruises on your head and arms, Maria. I'm here to help you. Everything we discuss in this room will stay between us.

Is it possible that someone physically hurt you? Maria: Yes doctor can only imagine that this must be very hard on you.

Is it your partner? Maria: Yes

PLEASE RESPECT OCD: INVEST YOUR TIME IN THIS

How did it start? suddenly (drugs) or gradually (stress)

Is this the first time? No

How long has this been going on? How often does it happen?

Is it getting worse?

Did he restrict you from seeing your family or friends?

Where are the injuries?

Severity Does he always injure your face? Does he injure other parts of your body?

Were you ever hospitalized for that?

Did you ever call the police for assistance?

Relationship with children

Do you have children?

Has he hurt you in front of them?

Has he ever hurt your children?

Spousal relationship

How's your relationship with each other?

How does he feel after hurting you?

Does he regret it? Does he feel guilty?

What's his reasoning for that?

Screen Husband

Does he drink?

Does he do drugs?

Does he suffer from any psychiatric illness?

Any chronic illness?

Has he had any recent stress in his life?

Does he have a family history of sexual or physical abuse?

Any financial problems?

Is your family aware of the situation?

Screen for wife

Stress

Alcohol

Drugs

Psychiatric disease

Chronic disease

How is your mood? MI PASS ECG

Suicide, homicide

For the future:

Do you have a plan in case this happens again?

Do you have safe place to go?

I suggest take some money, clothes, and important documents to a safe place, in case you to leave your home quickly.

Maria, I am concerned about your safety. What he's doing is a criminal act. The situation may worsen with time & may impact your children.

You don't have to live like this. You can seek police protection by personally reporting him. I can arrange a meeting with a social worker that can help guide you.

Would you like to speak with your family, now?

Arrange for a follow-up visit. Do you have any questions?

Spousal Abuse: Jack Jefferson hurt his wife Sara Anderson this morning. They're both in the ER & Sarah is doing some x-rays. Jack would like to talk to you. Counsel him.

You will do the same. Be supportive to the husband, he feels guilty.

How did it start? suddenly (drugs) or gradually (stress)

Is this the first time? If yes -9 no further questions in OCD. If no continue with OCD.

How long has this been going on? How often does it happen?

Is it getting worse?

Do you restrict her from seeing her family or friends?

Where are the injuries?

Severity

Do you always injure her face? Have you ever injured other parts of her body?

Was she ever hospitalized for that?

Did she ever call the police for assistance?

Relationship with children

Do you have children?

Have they ever seen you hurt her?

Have you hurt your children?

Spousal relationship

How's your relationship with each other?

How do you feel after hurting her? I feel guilty Physician: Yes, I can tell.

What's your reasoning for doing that?

Screen Husband

Do you drink? Yes CAGE, ask him if he's willing to quit

Do you use drugs?

Do you suffer from any psychiatric illness?

Any chronic illness?

Have you had any recent stress in your life? Yes, I'm stressed at work.

Does he have a family history of sexual or physical abuse?

Any financial problems? Yes

How is your mood?

Is your family aware of the situation?

Ml PASS ECG

Suicide, homicide

Screen for wife

Stress

Alcohol

Psychiatric disease

Chronic disease

Next time:

By speaking with you, I can see that you regret what happened. You're concerned for your family's safety and the consequences of your actions. We will arrange for a family meeting,

Social worker (CBC) for financial problems

Alcohol cessation program

One strategy you could try, is taking a TIME OUT !!!! It implies leaving the situation, in which the conflict is occurring, giving each other space until you both settle down.

1.Recognize the triggers and signs that lead to this behavior, and learn how to respond if the situation escalates. Stop whatever you are doing!

2.Tell your partner that you need some space to cool down and sort things out. Physically remove yourself from the situation. Go somewhere you can think, free of alcohol and drugs. You could also go somewhere quiet. Some people find that physical activity, such as walking, playing their favorite sport helps them release their frustration.

3.If possible, talk to someone you trust, such as a friend, an elder, a family member, or a preacher.

4.Take deep breaths. Relax and try to reflect on what happened. What triggered the anger? Tell yourself to let it go, & stop focusing on what made you angry.

Arrange for follow-up

Commitment to the plan

The examiner: How will you respond if the police asked you to inform them about what happened?

I will not break my patient's confidentiality

Case 4:

60 years old lady has difficulty coping life at home. Take relevant histom Do not check her for mental status examination. Do not do cognition test.

The pt. will have bruises over her face and body and a band around her wrist.

Be supportive, mention her name throughout the conversation Physician: Can you let me know what happened?

Pt.: I do not feel well at my home and want to go to nursing home.

Physician: Mrs.... There are bruises on your head and arms; I'm here to help you. Everything we

discuss in this room will stay between us. Is it possible that someone physically hurt you?

Pt.: Yes doctor

Physician: I can only imagine that, this must be very hard on you. Is it a family member??

Pt.: Yes, It is my son.

PLEASE RESPECT OCD: INVEST YOUR TIME IN THIS

How did it start? suddenly (drugs) or gradually (stress)

When did it start? ----> After her son moved to live with her 1 month ago

Is this the first time?. No

How often does it happen?----> He pushed me 2 times before

Is it getting worse?

Did he restrict you from seeing your family or friends?

Where are the injuries?

Severity

Does he always injure your face? Does he injure other parts of your body?

Were you ever hospitalized for that?

Did you ever call the police for assistance?

Relationship with the rest of the family?

Any other body lives with you?

Any children in the house?

Mutual relationship

How's your relationship with each other?

How does he feel after hurting you?

Does he regret it? Does he feel guilty?

What's his reasoning for that?

Screen Son

Does he drink? -+ve Alcohol Does he do drugs?

Does he suffer from any psychiatric illness?

Any chronic illness?

Has he had any recent stress in his life? ----> recently divorced Does he have a family history of sexual or physical abuse? Any financial problems? Screen Pt.

Stress

Alcohol

Psychiatric disease

Chronic disease

How is your mood? -Ml PASS ECG

Suicide, homicide

ADL ---> all normal For the future:

Do you have a plan in case this happens again? Do you have safe place to go?

Counselling:

Mrs. .... I am concerned about your safety. What he's doing is a criminal act. The situation may worsen with time & may impact your life. There is no need to go to nursing home. You don't have to live like this. You can seek police protection by personally reporting him. I have to document all evidence of abuse in your chart, I suggest that you have an exit plane in case this happen again; you take some money, clothes, and important documents to a safe place, in case you had to leave your home quickly.

I can arrange a meeting with a social worker that can help guide you.

Offer to send someone to assess safety at home.

Offer family meeting to help resolving the issue.

Offer anger management program for the son.

Arrange for a follow-up visit. Do you have any questions?

INDICATIONS TO REPORT:

1-Reporting elder abuse is mandatory when an older adult resides in a Long-Term Care Home or a Retirement Home and elder abuse is suspected or has occurred

2-Older adults with developmental disabilities are also protected with mandatory reporting legislation.

Case 5:

A mother comes to you for antenatal care. Counsel her.

2 questions

Physician: Congratulations! I'm glad you came to speak with me today.

How do you feel about this pregnancy?

How did you find out you were pregnant? When was your LMP?

Do you know your estimated due date?

Do you have nausea, vomiting, or morning sickness?

Breast tenderness, weight gain, edema, or cramping?

Obstetric history

Have you been pregnant before?

How many kids do you have?

What's the age of your eldest child?

Sexual Hx

General Questions: family hx of abortion, genetic disease.

Do you have any pets at home?

Was this a planned pregnancy?

How do you feel about it? How does your partner feel about it?

Has your partner ever physically or sexually abused you?

General questions

Counseling

The 1st trimester is a critical time for both you and your baby because it's the time your baby's organs begin to form.

Eat healthy meals & take a folic acid and vitamin supplement. Folic acid helps prevent neurological anomalies. Do not smoke and avoid second-hand smoke. Do consume alcohol, limit your caffeine intake and stay away from cat litter.

To prevent and control nausea, eat dry crackers 15 mins after getting up in the morning. Eat small, frequent meals. Drink enough fluids during the day. Don't lie down immediately after eating. Avoid cooking food that triggers your nausea. If your nausea and vomiting become severe, come and see me.

You should gain approximately 0.5 lb/wk in the first 20 weeks. After 20 weeks, you will gain 1 lb/wk until the delivery. You should come into see me once a month until 32 weeks. Between 32-36 weeks, you should come in twice a month. After 36 weeks, until the time you deliver, we will meet every week.

Do not take medication without consulting me.

You can do mild physical activity; it's good for the pregnancy.

You can have sex except during the last 2 weeks.

I will examine you and send you for some investigations. There are many classes on antenatal care. The secretary will help you enroll for those classes and can provide you with pamphlets on antenatal care.

Do you have any questions?

A 37y old female is 9 weeks pregnant. She's here to discuss genetic counseling. Counsel her without taking a history.

3 questions of counseling

At your age (37 years), your baby is at a higher risk for genetic abnormalities, especially if this is your first pregnancy. We will follow your pregnancy as we typically do, but we will also run some specific tests that screen for common genetic abnormalities.

One of these genetic abnormalities is Down syndrome. Are you familiar with it?

How much would you like to know?

Down syndrome is a genetic condition in which extra genetic material causes delays in the way a child develops, both mentally and physically. Usually, children born with the condition have some degree of mental retardation, as well as characteristic physical features.

Another anomaly is called Neural Tube Defects

NTDs are birth defects of the brain, spine, or spinal cord. It's a serious condition.

Since you're 9 weeks pregnant, the earliest test we can do is Chorionic villous sampling. This test can be done between 10-12 weeks gestation. We insert a needle using an ultrasound through the abdomen or cervix.

Patient: A needle!

Physician: Yes, it's a fine needle. The needle will take a piece of tissue from the placenta. Patient: Is it serious?

As with any procedure, there are always risks. There is a 1% chance of spontaneous abortion or fetal limb injury. This test doesn't screen for NTDs.

The second test we can use is an ultrasound between 11-13 weeks to see if you have fluid collection at the back of the neck.

Amniocentesis is a test that is done after 15 weeks. In this test we insert a needle through the abdomen or cervix

Patient: A needle!Physician: Yes, it's a fine needle.

Patient: Is there also a possibility of spontaneous abortion and fetal limb abnormality?

Physician: Yes, it's 0.5%. Amniocentesis is preferred over CVS to diagnose NTD.

Are you following me? Am I clear to you?

There is another screening test called the Triple Marker Screen & it detects up to 90% of genetic diseases.

I just want to clarify that if these screening test results are negative, that doesn't guarantee that your baby is immune to other abnormities. If you were to discover that your baby had a genetic abnormality, it would be your choice whether or not you would like to continue with the pregnancy. The body has a natural selection process that lets healthy pregnancies continue, while weaker ones may be aborted. If this were to happen, it is not your fault.

One of the options is abortion, are you interested to know information about it? (explain briefly) You do not need your husband's consent to have an abortion; however, in such a case, I recommend that you share this information with him, as you'll need his support.

How do you feel about that?

If time permits, after genetic counseling, we can do antenatal counseling.

A patient came in for breast feeding counseling

Patient: I just delivered my baby, Dr.

Physician:_ Congratulations, what's his name?

Patient: Skylar Physician: That's a great name!

Obstetric History

Birth history

Was your baby fine after the delivery?

Does your baby have any congenital anomaly in his such as a mouth cleft lip or cleft palate?

Did you notice any yellowish discoloration of his skin?

Contraindications of breastfeeding

HIV: Do you know your HIV status? Ask questions for AIDS T B: Do you have TB? Fever or night sweats?

Herpes: do you have any herpes infection on your breasts?

Are you taking any medications such as lithium, antibiotics or chemotherapy?

General: alcohol consumption

Benefits

Breast milk provides all the nutrients your baby needs. It's also protective against bacteria and allergies. It's also very convenient, as it's always available & doesn't require preparation.

There's no risk of contamination & it's free!

Breastfeeding helps form a psychological bond between you and your baby. It gives your child a sense of security.

Are you following me?

It helps prevent breast, ovarian and uterine cancer.

The feeding position is up to you you're both comfortable and your baby has access to your breast.

We can offer you to speak with a specialist that can educate you about breastfeeding. Start by placing your nipple in your baby's mouth. The child will start sucking the milk. After 20 mins, switch to the other side.

In first few days of breastfeeding, secretions called colostrum come out instead of milk. Colostrum contains nutrients and antibodies.

You may have nipple pain, but it will go away in few days. If your breast becomes inflamed come in and see me. The first few days, your baby may have loose stools. This is normal.

While breastfeeding, you should eat well, drink plenty of fluids, stop smoking and take a multivitamin.

After 6 month of breastfeeding, you can introduce your baby to other foods.

As for contraception while breastfeeding, you can use condoms or progestin-only birth control pills

I will provide you with a pamphlet about breastfeeding. Do you have any questions?

39y-old wants to quit smoking. Counsel him.

Physician: As I understand, you're here today because you'd like to quit smoking. I'm really happy to hear that and am ready to help you.

3 questions of counseling

When do you want to stop smoking?

Please rate your motivation to stop smoking on a scale from 1-10.

How much do you smoke? How long you have been smoking?

Do you drink alcohol?

Do you do any drugs?

Have you shared this decision with your family?

Are they supportive to you?

Do you know anyone who successfully quit smoking?

Is this your first time trying to quit?

Patient: No, it's not my first time. What do you think caused me to fail?

Physician: It could happen to anyone, you can try again.

Do you have heart disease, chest pain, SOB, weakness, numbness, loss of sensation, stroke, chest disease?

Do you suffer from a seizure disorder?

Do you have an eating disorder?

From 1-10, how important is to quit smoking?

From 1-10, how confident do you feel that you can quit smoking?

General Questions

Be a star and a funny doctor

S: set a date

We need to set a date within one month. It's a good idea to choose a special date, such as someone special's birthday. Before the date approaches, you should have reduced your smoking. The goal is to have quit smoking by the chosen date. T: Tell you family about your decision and ask them to support you.

A: Anticipate withdrawal symptoms

Headaches, sleep disturbances and weight gain

R: Remove your lighter or matches from your home.

Avoid accompanying people who smoke.

When you feel the need to smoke, drink water.

If you succeed in quitting, reward yourself (but not by smoking!)

If you are not successful, don't get discouraged, and try again.

There are some medications available. I don't think you need them now, but I think you can give it a shot without any meds. Initially, I'd like to see you every week, and then monthly.

By quitting smoking, you'll be setting a good example for others, saving money and most importantly your health.

I'd like you to stay strong, as the highest rate of failure is within the first 3 months of quitting smoking.

After 1 year, the risk of coronary heart disease is cut in half.

After 5 years, the risk of stroke falls to the same as a non-smoker

After 10 years, the risk of lung cancer is cut in half, and the risk of other cancers decreases significantly.

After 15 years, the risk of coronary heart disease drops, usually to the level of a non-smoker Most people gain weight while quitting. You can avoid this by eating well and being physically active.

Arrange for follow-up

A patient wants to stop drinking alcohol.

Congratulations it's a good idea

How much do you drink?

How often?

How long have you been drinking? CAGE questionnaire

Do you smoke? Do you do any drugs?

Do you drink alone or with friends?

Do you drink and drive?

Any liver disease?

Any stomach ulcer?

Any urinary problems? Pancreatic disease?

Any problems walking?

Do you feel down?

Do you have any ideas of hurting yourself?

Has your drinking caused any problems at work?

Has your drinking caused any problems at home?

Have you tried to quit drinking alcohol before? If yes

what was the reason for failure?

Ask about withdrawal symptoms such as: Nausea, vomiting, shaking, visual hallucinations As you know, alcohol places stress on your liver, stomach & pancreas. It can increase the risk of pancreatic cancer. It can also cause depression & may negatively impact your loved ones (children). We'll need to admit you to the hospital or a rehabilitation center, as there may be some lifethreatening complications such as seizures, vomiting, hallucinations and shaking.

You should let your family and friends know about your decision to quit.

If you succeed in quitting, you should reward yourself (but of course, not by drinking)

If you fail, we can try again.

We also need to consult a psychiatrist.

Do you have any questions?

A mother is concerned about peanut allergy for her child, counsel her

3Qs

What's his name? repeat the name!

OCD

How did it start? All of a sudden?

When did it start?

Is this the first time he has allergy?

Apart from eating peanuts, does anything else make it worse (medication or food)?

Severity of the attack

Is he able to speak during the attack?

Did he turn blue during the attack?

Did he go to the hospital?

During the attack, did he take any medication?

Is he currently taking any medication now?

Symptoms of allergy

Does he have nausea, vomiting, noise in the chest, difficulty breathing, SOB, redness, swelling or itching?

Fhx of allergy & Pediatric Questions

During the pregnancy, was he full-term or pre-term?

Did you have any complications during your pregnancy?

Were you exposed to a child with a fever or rash?

During the pregnancy, did you smoke or drink alcohol?

What was the mode of delivery (NVD or CS)?



Any complications during delivery?

Immediately after delivery, what was his Apgar score

The mother will say it was ok or may ask what is the Apgar score? You will respond, your baby was fine after the delivery

Did he have any congenital anomalies after delivery?

Was he bottle-fed or breastfed?

Are his immunizations up-to-date?

How about his development? Learn the developmental milestones

Counseling

After milk and egg allergies, peanut allergies are the most common childhood allergies. The allergy is the body's response to an allergen. The most common cause of this allergy is eating peanuts. However, peanuts mixed in foods can cause a reaction. Sometimes, peanuts are unintentionally introduced to other foods in the factories.

It's not clear why some patients have peanuts allergies and other don't. It may be related to genetics, as there's a higher chance when there's a family history.

About 1 in every 5 children with a peanut allergy will continue to have this allergy in adulthood. The only way to prevent this allergy is avoidance. Make sure to carefully read food labels. Avoid food containing peanuts or food produced in factories that process peanuts.

Are you following me? Is this clear?

Talk with your childcare provider. Talk to the parents of your child's friends, as well the friends. Tell them that your child is allergic to peanuts. Sometimes it is very serious that requires immediate action. Make sure that your child knows how to ask for help if he has allergic reaction. Educate the adults around your child about the allergic symptoms and signs.

Have your child carry an epipen all the times, in case of he has a reaction. Check the pen's expiry date. Have your child wear a medical bracelet. Discourage your child from sharing food.

You are a family practitioner. Your patient is scheduled for a Total Hip Replacement. Take a history to assess his medical fitness.

What type of surgery?

Why are you having this surgery?

Patient: I have fracture, RA, malignancy

How do you feel about having this surgery?

Any investigations done before?

Do you have any heart disease, lung disease, liver disease or kidney disease?

Are you taking any medication? Can you show me the list

Are you taking any blood thinner?

What type of anesthesia you will have?

I'd like to do a physical exam and send you for some investigations.

As with any procedure, there is a risk of side effects or complications.



You may experience post-operative pain, so we'll take that into consideration and give you some painkillers. DVT is a possible complication, we will give you blood thinners. There are other complication such as atelectasis and infection at the surgery site and there is also a possibility of mortality. Are you following me?

The anesthesiologist and surgeon will see you before the surgery and explain their role and procedure. You have to sign consent for both of them. Your last meal should be 8 -12 hours before the operation.

A nurse came in with a needle stick injury

3Qs

OCD

When did it happen?

How did it happen?

Where did it happen?

Was it during the injection or withdrawal of blood?

Was the needle bloody?

What was the size of the needle?

How deep did it penetrate?

Did you use any gloves?

Any vaccination before such as HBV and tetanus.

Some Qs about the patients

Do you know his HIV status?

Do you know the patient's HBV or HCV status?

Is he homosexual?

Is he an IV drug abuser?

What about you

Do you have HIV?

Do you know your HBV or HCV status?

Are you a homosexual?

Are you an IV drug abuser?

Any blood transfusion?

Is it possible that you are pregnant?

What did you do after the puncture?

Counseling: role of 3

Needle stick injuries increase the risk of hepatitis B by 30%, increase hepatitis C by 3% and HIV by 0.3%. Every healthcare provider should be vaccinated and have their titre checked regularly. Wearing gloves are mandatory. Taking anti-viral medication can reduce the chance of infection by 80%. Of course you should practice safe sex. If the patient is hepatitis B positive, and you are vaccinated, no treatment, we will follow you for 6 months.

If the patient is hepatitis g positive, and you are not vaccinated then you will get Immunoglobulin and vaccine. We will monitor you for 6 months. If the pt is HIV positive, combination therapy should be started as soon as possible for 4 weeks. If pt is HIV negative, there is a window period . We will check you now, after 6 weeks, and after 6 months. Please during this period have safe sex. Now we are going to send you for a blood test for liver disease and HIV. The results will be ready after 2 weeks. If the result is positive, we must report this to public health. Always handle sharp objects with care.

How's your mood?

Are you going to hurt yourself?

Are you following me?

Practice Safe sex

Do not donate blood

Social worker

I will file an incident report

Follow-up

Commitment for the plan

A janitor at a school found a needle. She tried to get rid of it, but accidently pricked herself.

Advise her to practice safe sex & not to donate blood

Must report the incident

The examiner will inform you that she has multiple sexual partners and is (+) for AIDS

Report to public health, practice safe sex, contact previous sexual partners

Pre-emplovment counseling

The same as pre-operative counseling

What was your previous job?

What are you doing now?

Patient with osteoporosis (menopause or fracture) 60-year-old female with sudden onset of upper back pain in midline. It occurred suddenly. after coughing. Take a history.

OCD/

PAIN ANALYSIS

menstrual Hx

Obstetric Hx

Gynecological Hx

Did u use OCP?

Did you breastfeed your kids?

Symptoms : Ask about the following symptoms:

1.Compression fracture related symptoms: back pain, decrease in height, fracture

2.Disc herniation related symptoms: Loss of sensation, weakness, saddle anesthesia

3.Menopause/ postmenopausal related questions: hot flashes, mood swings, bladder control, urinary frequency.

RISK FACTORS for Osteoporosis:

4.Fhx of Osteoporosis

5.Hyperparathyrodism : swelling in your neck

6.Do you exercise?

7.How about your diet? (do you drink milk)?

8.Do you take steroids or thyroxine?

9.Any changes in your weight?

10.Do you have RA?

11.Do you smoke, drink ETOH, or do drugs?

MSK

General Q

Counseling

information about the Disease:

Osteoporosis, is the most common human bone disease, and is caused by low bone mass and deterioration of bone tissue, which leads to bone fragility, and an increase in risk of fracture.

a.Who is at Risk:

Postmenopausal Caucasian women are at highest risk; but, it can also affect non-Caucasian women and men.

b.What are the Risk Factors:

There are only 30% of patients with osteoporosis that have known risk factors- and some of these risk factors, unfortunately, come with life and we can't do anything about them, such as:

Personal history of broken bone as an adult history of fracture in first degree relative (like mom, dad, or siblings)

Caucasian race Advance age Female sex

Dementia generally poor health and frailty.

But some of them, fortunately, we can potentially modify and fix, such as:

current cigarette smoking low body weight (<127 lbs. For average height).

Estrogen deficiency: this can be caused by different things such as: menopause, early menopause (age <45), prolonged premenopausal amenorrhea (>1 year ), life long low calcium in diet, excessive alcohol intake, impaired eyesight, recurrent falls, inadequate physical activity, or general poor health and frailty.

C.How to Prevent it: As you know, with all diseases, it's better to prevent it, rather than treating it. So, let's see how we can prevent osteoporosis.

Well, number 1, is to know about all the risk factors that we just talked about, and specially modify the ones that you can have control over, for example, Quitting smoking.

Calcium and Vitamin D play a big role as well. So an adequate intake of at least 1,200-1,500 mg of calcium and 400-800 units of Vitamin D is very important.

Exercise, specially weight-bearing and muscle strengthening exercises are important too as they improve bone health, strengthen muscles, and improve balance (which will help prevent

It's also very important to prevent falls to begin with. So, tape down rugs, use night lamps, and etc.

Keeping alcohol intake moderate, which means maximum of one drink per day. (12 oz beer, 5 oz wine, and 1.5 oz liquor).

You can also get a bone mineral density (BMD). We don't routinely recommend BMD to everyone, but some of the people that we do recommend are the following: if you are: Older than Age >50 yr:

Age >65 (both men and women) o clinical risk factors for fracture (menopausal women, men age 50-64) fractures that are caused by weak and fragile bones, after age 40 yr Prolonged use of steroids (more than 3 months in the past year )

Hip fractures in parents o Vertebral fractures identified on radiography o current smoking high alcohol intake low body weight (< 60 kg) or major weight loss (> 10% of body weight at age 25 yr) o Rheumatoid arthritis

Other disorders strongly associated with osteoporosis o Younger adults Age < 50 yr fractures that are caused by weak and fragile bones prolonged use of steroids (more than 3 months in the past year ) early age menopause (age <45 yr)

Diseases that cause decreased absorption of food and nutrients Over functioning of parathyroid gland

Other disorders strongly associated with rapid bone loss and/or fracture.

D.How to Diagnose it:

Bone Mineral Density is the most common and accurate way of diagnosing osteoporosis.

We can also do some blood tests such as Calcium and vitamin D levels, CBC, Alka'ine phosphatase, creatinine, TSH

How to treat it once you have it:

- Some of the common ways to treat osteoporosis is finding out what might be causing it and trying to fix that. For example, if steroids are causing it, stopping the steroids -is the first step, and if lack of estrogen is the likely cause, then replacing that estrogen is important. But, generally, the decision to treat someone for osteoporosis depends on the BMT results. So, some of the medications we use to treat Osteoporosis are :

HRT: This is effective to prevent and to treat postmenopausal osteoporosis for the duration during which it is used. They prevent bone loss in women in the early and late postmenopause. Studies show that 50-80% of vertebral fractures and 25% of non-vertebral fractures will be prevented by these with 5 or more years of use; and if patients take these medications for 10 or more years, then 50-75% of ALL fractures will be decreased.

We also have some drugs such as Alendronate, that is a drug from a class called: Bisphosphonate. This drug has been approved for prevention and treatment of osteoporosis. How it works is that, it prevents bone loss in postmenopausal women, and therefore, prevents fractures mainly in the spine, hip, and wrist by 50% in patients with osteoporosis.

It stops bone loss, and preliminary data in women with osteoporosis show that it reduces the risk of vertebral fracture by about 40-50%. It is less effective than ERT/ HRT, alendronate, and risedronate though.

Case 2:

Brain death for organ transplantation:

I have some news regarding Mr. Miller's condition. As you know, we did everything possible to improve his condition, but things are getting worse because of massive trauma of the head.

Currently in Canada the legal definition of death can be met by 2 different criteria:

1.Discontinuation of heart and lung function meaning that heart beating has stopped and there is no longer breathing and this is irreversible

2.Second criteria is the arrest of the whole brain function meaning that the heart is working with technical support I mean a machine so withdrawing the patient from a machine will result in heart death as well. Unfortunately, that's what happened to Mr. Miller.

Two doctors came and declar„ed that he is dead wait for the emotion and give tissue. I know you are having a hard time, but I need to continue my questions are you comfortable? OK

Now I would like to know do you have any idea about organ donation. Most organ donations for organ transplantation are done in the setting of brain death.

The non-living donor is kept on mechanical support until a sick patient needs one of the organs of Mr. Miller to help him to survive.

If a brain dead person is not an organ donor, mechanical and drug support is discontinued and cardiac death is allowed to occur. donation requires the approval of the patient through advanced directive or by a living person who know Mr. Miller and can decide according his previous wishes that he can donate his organ to help sick people to survive.

Mr. Miller is a good candidate for organ transplantation, are you following me? BTW did Mr. Miller express his wishes before regarding organ donation? Does he have any advanced directives? Some people refuse organ donation for religious reasons? Other feels comfortable in knowing that something of their love persons is still lives on by giving the gift of life to someone in need.

How do you feel about that? How is your mood? I would like the family to take some time to think about this decision and if you would agree with me we can arrange a family meeting? To discuss this issue again? Do you have any questions?

Nice to meet you.

Case : Patient pregnant and lost previous pregnancy due to alcohol and is still drinking

I-Antenatal counseling question: how do you know you are pregnant?

All blocks: Menstrual, obstetric, gynecological, sexual,

2- Alcohol counseling questions: Amount? Cage? Legal problems? Etc....

3-Mrs Sarah Anderson that one thing is clear if you are pregnant and take a drink? Your baby takes the same drink; there is no known safe amount of alcohol to consume while you are pregnant. There is serious condition called fetal alcohol syndrome, your baby will have a serious handicap, as a result will require a life time of a special care in addition your baby will be small in size and weight and will have a slower development, small head , facial anomalies , organ deformities, heart defects, genital anomalies, small brain, and mental retardation.

If she refuses to stop offer therapeutic abortion

4-Counse'ling: Antenatal as usual; eat, exercise Etc....

PEP: what work up are you going to do?

a) Usual pre-natal testing

-Complete exam (BP and weight / Pelvic exam)

-CBC, blood group and type, Rh antibodies,

-Infection screening (Rubella, HBsAg, VDRL, Pap smear, gonorrhea/chlamydia, HIV)

-Urine analysis, C&S (bacteriuria and proteinuria)

-Cervical culture for N. gonorrhoeae and C. trachomatis, vaginal swab for bacterial vaginosis (BV)

b) Specific tests (for alcoholics)

-Blood alcohol level (if intoxicated)

-AST, ALT (usually AST:ALT approaches 2:1 in an alcoholic) - INR (decreased clotting factor production by liver)





Case 2:

The 40-year-old son of a 70-year-old patient came to visit her at the nursing home today.

His mother has diabetes, Alzheimer's disease, as well as mild recent and distant memory impairment. Normally, she takes 15 units of insulin at night; however, last night, someone gave her 30 units.

As a result, this morning she woke up agitated with delirium. Her son is upset because she was unusually agitated and didn't recognize him, as she normally does. Her son is authorized to know her medical condition. Disclose the problem. Talk to her son and explain what happened with his mother's insulin dose.

Use a lot of empathy and emotions, t understand your frustration and I totally AGREEE with you Mr. Jack Anderson thank you for coming today as I have something important to tell you.

Assure confidentiality

Unfortunately your mother received by mistake a higher dose of insulin, It is very hard for me to say, that but you need to know the truth...' understand how you feel at this time..

Let the patient express his emotions. Do not interrupt him

We have taken all necessary steps to correct situation and your mother received all the necessary treatment and remain under monitoring...

We have already discussed this problem and reported the error to our hospital health authority. We will investigate as well as take the necessary measures to avoid this error in the future. In addition, we will inform your mother and apologize to her when her health improves.

I know your mother has been here more than 4 years..has any similar issue happened before?

He replied: I'm happy from the service you've given during these 4 years, 4 years without problems what so ever.

How is the relationship between you and her?

Did you see your mother this morning?

How is she doing?

How often you visit her? 2 times per week

Your support is very important to her.

How is your mood now?

Suggest a family meeting to discuss this issue.

Any questions or concerns

You are the surgical resident on-call. A 60-year-old male just arrived to the ward.

He is scheduled for colon surgery tomorrow. Known for: hypertension, Type 2 Diabetes Meds: Coumadin for previous DVT

Take an informed consent in 10 minutes.

Doctor: Good morning Mr. I see here that you're scheduled for surgery tomorrow.

How do you feel about that?

Patient: I feel ok. Ready to get this over with.

Doctor: I'm here to take a consent from you. Before we start, I'd like to assure you that all information will be kept confidential between us.

Did you have the chance to discuss this surgery with your surgeon in the clinic?

Patient: Not really, Doctor. My surgeon told me that you'll explain the surgery to me.

Doctor: Your surgery will be done using an open technique to remove the part of your colon that contains the tumor.

The surgeon will make a 6- to 8-inch cut in your lower belly.

The surgeon will find the part of your colon that is diseased.

The surgeon will put clamps on both ends of this part to close it off.

Then the surgeon will remove the tumor.

If there is enough healthy large intestine left, your surgeon will sew or staple the healthy ends back together. Most patients have this done.

If you do not have enough healthy large intestine to reconnect, you may have a colostomy.

In most cases, the colostomy is short-term. It can be closed with another operation later. But, if a large part of your bowel is removed, the colostomy may be permanent.

Your surgeon may also look at lymph nodes and other organs, and may remove some of them. Colectomy surgery usually takes between 1 and 4 hours.

Regarding the risk of the surgery.

As with any surgery, you run the risk of:

Blood clots in the legs that may travel to the lungs

Breathing problems

Heart attack -or stroke

Infection, including in the lungs, urinary tract, and belly

Risks for this surgery are:

Bleeding inside your belly

Bulging tissue through the surgical cut, called an incisional hernia

Damage to nearby organs in the body

Damage to the ureter or bladder

Problems with the colostomy

Scar tissue that forms in the belly and causes a blockage of the intestines

The edges of your intestines that are sewn together come open (anastomotic leak this may be life-threatening) Wound breaks open (dehiscence)

Wound infections

I'd like to assure you that if any of the above were to happen, we have special techniques to detect them early on, and we'll do our best to manage them appropriately.

Did you stop your Coumadin?

Patient: Yes, 7 days ago.

Doctor: That's good. As you know, Coumadin is associated with risk of bleeding.

Due to your past medical history, you run a higher risk of having clotting again. This may lead to the migration of clots to your lungs, which is a serious condition.

For all these reasons, we are going to give you some medication that will control your clotting. You are going to wear elastic stalkings and I'm going to the hematology team to take their opinion. Do you have any questions?

Patient: No Doctor. That's' fine

Doctor: Regarding the anesthesia, the Anesthesiologist will come and explain his part to you.

I'd like you to be aware that there is a small risk associated with anesthesia, including difficulty awaking and even death.

We'll give you some medication to help you control your pain after surgery.

Do you have:

Heart Disease

Lung Disease

Liver Disease

Kidney Disease

Do you smoke

Drink alcohol

Allergy

Fever

Any medical illness

Are you taking any medications other than Coumadin? If so, do you have this list?

With regards to food/drjnk, do NOT drink anything after midnight, including water. Sometimes you will not be able to drink anything for up to 12 hours before surgery.

By the second or third day, you will probably be able to drink clear liquids.

Your doctor or nurse will slowly add thicker fluids and then soft foods as your bowel begins to work again.

This is a teaching center. There will be some students and medical residents sharing in your care.

This consent is not a contract, so you have your right to change your mind any time before the surgery.

Do you have any questions?

Patient: No, I think you covered everything

Doctor: I'd like you to sign here please. Afterwards, I'll conduct a physical exam and check the results of your blood test.

Sara Jefferson is the daughter of 75 year old woman with recent incontinence and mood changes. Review her pharmacological treatment and manage her medications. (Labs are normal)

-OCD mood changes: How? When? First time?

- Ok, let's go over the medications together

Patient will show you a list containing the following meds:

trazodone ,diazepam,oxybutynin , HCTZ , Tylenol , Salbutamol and ipratropium For every med ask the usual disease and meds Qs: Why does she take the med? Since when? Does she take it regularly? Does it control the symptoms? last check up with the Dr.? The results? Any investigations?

Ask about side effects of the med.

Why she takes salbutamol and ipratropiun pumps?

The daughter will say that the mother has COPD.

Ask the usual disease Qs:

does she take the medications regularly?

do they control the symptoms?

last check up with the chest Dr.?

The results? Any investigations?

Ask about side effects: -Salbutamol/ipratropium: Dry mouth, irritated throat, dizziness, headache, heartburn, loss of appetite, anxiety, nervousness, trembling, and sweating.

Why she takes Tylenol? Daughter will say that mother has arthritis.

Do the same thing as above with disease and med questions.

Any abdominal pain, changes in color of stools/ urine

Why she takes HCTZ? Daughter will say that mother has hypertension

Then the disease and med questions

Ask about side effects:

Drowsiness

Fast heartbeat;

Muscle pain or weakness;

Numbness or tingly feeling;

Skin rash

Nausea, itching, loss of appetite, dark urine, clay-colored stools, jaundice

Blurred vision eye pain

Results for the electrolytes are written on the case instructions paper and indicate that electrolytes were normal, so HCTZ is not causing her confusion.

Why she takes Trazodone? for sleep/depression.

Disease and med questions.

Ask about side effects

confusion

fainting

Feel heart racing

tremors

skin rash

blurred vision

dizziness

headache

muscle aches

unusual tiredness or weakness

Why does she take diazepam?

Disease and meds questions.

it causes paradoxical irritation in the elderly and increases the risk of falling and we will stop this medication side effects:

drowsiness

slurred speech

anxiety

confusion

depression

fast, pounding, or irregular heartbeat

lack of memory oxybutynin for incontinence: (recently started) If this medication is not controlling her symptoms, we will change it to another group of anti-incontinence meds that are more efficient.

Side effects:

hot, dry skin and extreme thirst; severe stomach pain or constipation;

blurred vision, eye pain, or seeing halos around lights;

pain or burning when urinate -General and social blocks: fever, whom does she live with,-support

Old lady with decreased INR, talk to her about the result of the test.

We received your test results, unfortunately, we found the result lower than it should be.

Is this the first time you do the test?

What is your understanding about warfarin?

Are you followed up regularly by a doctor?

When was the last check up? What was the result?

Any other investigations done?

Why do you take Warfarin?

Since when do you take it?

Do you take it regularly? Did you miss any doses? Why?

Patient may say that she stopped Warfarin because her cousin died due to ICH while taking Warfarin.

Oh, I am sorry to hear that, it must be so hard for you

Was she followed up regularly by a doctor?

Did she have her blood test done regularly?

How do you feel about that? How is your mood?

Well Mrs. J, there are possible side effects of Coumadin.

The most concerning side effect is the bleeding.

THESE SIDE EFFECTS CAN BE PREVENTED AS LONG AS REGULAR BLOOD TESTS ARE DONE TO ASSURE AN APPROPRIATE DOSE IS GIVEN.

On the other hand, if you do not take Coumadin, you have risks of developing blood clots.

Blood clots can cause a stroke, heart attack, or obstruction in the blood vessels of the legs or lungs. Moreover, there are other causes of ICH than Coumadin, like hypertension, trauma and congenital anomalies of the blood vessels.

Are you following me? Am I clear for you?

Let me ask you some questions about your health, and then I will tell you more about Coumadin, ok?

-CVS Blocks, swelling, pain in your leg,

-General and social blocks (including medication and diet)

Now let me explain to you some more details about Coumadin.

Your regular blood tests...

Will check your response to Coumadin

This blood test is called INR

The goal is to keep your INR in a certain range. This will assure us that Coumadin is effectively working and help us avoid any side effects of the medication.

It is very important that you meet all of your lab appointments.

Your Coumadin dose...

May change based on your regular blood tests.

No matter what the dose, you must take your Coumadin everyday and at the same time every day.

If you miss a dose take it as soon as you remember. DO NOT double your dose the next day to make-up for the missed dose.

Try to avoid NSAlDs (ibuprofen, naproxen) and aspirin for pain or inflammation as these can increase your risk for bleeding while on warfarin. Recommend Tylenol for pain.

Large amounts of green leafy vegetables can lower the effects of Coumadin.

Avoid cranberry juice and alcohol.

Always alert any healthcare provider you interact with that you are on Coumadin.

Possible side effects of Coumadin are:

Bleeding problems and allergies.

The most concerning side effect is the bleeding.

Symptoms of bleeding are:

Headache, or weakness

Bruising

Bleeding from the nose or gums

Dark urine or dark stools

Vomiting blood or material that looks like coffee grinds

If any of these side effects or other unusual events occurs, go to emergency room or come to my office.

want to confirm to you again that THESE SIDE EFFECTS CAN BE PREVENTED AS LONG AS REGULAR BLOOD TESTS ARE DONE TO ASSURE AN APPROPRIATE DOSE IS GIVEN.

Blood clots can cause a stroke, heart attack, or obstruction in the blood vessels of the legs or lungs. These problems can appear as:

Weakness or numbness in extremities

Deterioration in your vision or hearing

Leg swelling, pain and discoloration

Sudden difficulty breathing, cough and chest pain

So, if you have any of these symptoms, go to emergency room immediately.

I will give you a brochure containing the most important information that you need to know about Coumadin.

Now Mrs. J., are you willing to take Coumadin regularly?

•If yes I will arrange for a follow-up visit in a few days. I will see you weekly until the INR level is normal, and then I will see you monthly.

•If no It is my duty to ensure that you understand all the facts and consequences about the medication, but at the end, the decision is yours. Take some time to think about it. If you change your mind, contact me and we can start the medication.

Thoracocentesis

Physician: Good morning Mr. I see here that you're scheduled for a Thoracocentesis tomorrow. How do you feel about that?

I'm here to obtain your consent. Before we start, I'd like to assure you that all information you provide is confidential.

Did you have the chance to discuss this procedure in the clinic?

Thoracentesis is a procedure for removing fluid from the space between the lungs and the inner chest wall. This space is called the chest cavity or pleural space.

A needle is used to remove the fluid under ultrasound guidance. Thoracentesis may be done for 2 reasons:

1.To remove fluid from the chest cavity that is causing difficulty breathing.

2.To get a sample of chest fluid to test for infection or cancer cells.

A build-up of fluid around your lungs may be caused by infection, cancer, liver disease, heart failure, thyroid disease, pancreatitis, a drug reaction, or kidney disease. A lab test of fluid samples will help to identify a cause.

You do not need to do anything to prepare for this procedure.

You will usually sit, sometimes backward on a chair with your arms resting on the back of the chair. The needle site will be cleaned and you will get a shot of painkiller to numb the area. Your provider will insert a needle through the skin, between the ribs, and into the chest cavity. It is important not to cough, breathe deeply, or move suddenly while your provider inserts the needle.

A small amount of fluid will be removed for testing. If there is a lot of fluid and it is making it hard for you to breathe, your provider will remove as much fluid as possible to improve your breathing. When the procedure is done, your provider will remove the needle and put a bandage on the needle site.

The test takes about 10-15 minutes.

After the procedure you may have a chest x-ray to make sure that the lung was not punctured by the needle. The x-ray will also show how much fluid is left in the chest.

Thoracentesis helps your provider diagnose an infection or tumor in the chest. Another benefit is that it will be easier for you to breathe after fluid is removed.

The main but uncommon risk is accidental puncturing of the lung when the needle is inserted or moved.

This is called collapsed lung or pneumothorax. When it happens, air leaks from the lungs and gets trapped in the chest cavity. A small leak is usually not a problem. The air is absorbed by the body over a few hours or a few days. The only treatment for a small leak may be follow-up chest x-rays to confirm that the air is being absorbed.

A larger leak may require treatment to remove the air from the chest and allow normal breathing. Other, uncommon side effects are infection and bleeding. Also, if a lot of fluid was removed, more fluid may build up in the lungs, depending on the cause of the fluid The area where the pleural tap needle goes is numbed by an injection of local anesthetic.

The Needle goes through the skin, between the ribs and into the fluid around the lung. If your physician discovers a different, unsuspected condition at the time of surgery, you will authorize him or her to perform such other Procedures.

Other alternatives: observation, chest tube, and antibiotics

This is a teaching center. There will be some students and medical residents sharing in your care. This consent is not a contract, so you have your right to change your mind any time before the surgery.



Do you have any questions? Questions:

Diagnostic Analysis of Pleural Fluid

pH level

Gram stain, culture

Cell count and differential

Glucose level, protein levels, and lactic acid dehydrogenase (LDH) level

Cytology

Creatinine level if urinothorax is suspected (eg, after an abdominal or pelvic procedure)

Amylase level if esophageal perforation or pancreatitis is suspected

Triglyceride levels if chylothorax is suspected (eg, after coronary artery bypass graft [CABG], especially if the inferior mesenteric artery [IMA] was used; milky appearance is not sensitive) Is it exudate or transudate?

Exudative pleural fluid can be distinguished from transudative pleural fluid by looking for the following characteristics (exudates have 1 or more of these characteristics, whereas transudates have none):

Fluid/serum LDH ratio 2 0.6

Fluid/serum protein ratio 0.5

Fluid LDH level within the upper two thirds of the normal serum LDH level

Transudative effusions result from decreased plasma oncotic pressures and increased hydrostatic pressures. Heart failure is by far the most common cause, followed by liver cirrhosis and nephrotic syndrome.

Exudative effusions result from local destructive or surgical processes that cause increased capillary permeability and subsequent exudation of intravascular components into potential spaces. Causes are manifold and include pneumonia, empyema, cancer, pulmonary embolism, and numerous infectious etiologies.

In depth assessment station (14 min): You can spend more than 2 mins reading instructions at door but it will be counted from your total 14 mins.

75 years old female lives alone had a fall 2 weeks ago and was admitted to hospital suspecting a vertebral fracture, she was found on floor by her housekeeper who visit her twice a week, her MMSE is 25/30 and her ADL is 8/10, after initial stabilization of her condition she was seen in a multi-disciplinary approach and they provided a report. (you should read it before entering), her medications include:

Tylenol, aspirin, multivitamins, Vit D, Calcium, Alendronate (bisphosphonates)

- You are the physician in charge and you will meet her now with one of the family members (Her daughter Mrs....... 43 yrs old) and you are asked to:

1)Address the pt. concern

2)Address the family member concern

3)Formulate a discharge plan for the pt.

Report:

Neuro Pschyciatric assessment: Pt with history of an old stroke (2 ys ago) CT scan was done, No major residual effect, Good cognitive function

Ophthalmology assessment: Foveal degeneration for follow up

Musculoskeletal assessment: Chronic arthritis, need to use a 4 wheel chair during walk

Social service: for frequent assessment and follow ups.

Scenario:

-You will enter the room and find that the mother (with facial bruises and bandage around her Lt. arm) and the daughter arguing with each other for about 1-2 minutes (do not interrupt them), the mother wants to go home and the daughter thinks that it is not safe for her mother to be discharged now.

-Start by greeting both of them and introduce yourself then talk with the Pt.

Dr: Hello Mrs. how do you feel today?

Pt.: I am great Dr. and I am ready to return home as soon as possible

Daughter: No Dr. she is not ready, it will be very dangerous for her to be discharged in such condition

Dr.: I understand your concern but to be able to take a decision about this issue we need to go through a few Qs first to evaluate her globally, is it Ok with you Mrs..... ? let us try to make this meeting as positive experience as we can

Pt.: Sure Dr., but I am assuring you that I am totally fine and ready to go home

Dr: OCD of the fall? (How and When)

Pt.: I felt down two weeks ago, after my leg stuck in the carpet

Dr: Is it the first time?

Pt.: No, I had 2 other falls in the last 6 months

Dr: Did you lose your consciousness after falling?

Pt.: I am not sure? But I felt pain in my back

Dr: anybody around you?

Pt.: No

Daughter: she was found by her housekeeper after 4 hours of falling

Dr: Do you have any problem during walking?

Pt.: No, I do not have

Daughter: But she is supposed to walk with a cane after her last stroke but she refuses to use it?

Dr: When did she have this stroke?

Daughter: 2 yrs. ago

Dr: Do you have any problem in your vision?

Pt.: Yes, and I wear a contact lenses for my poor vision

Daughter: Again Dr. She doesn't always use them.

Dr: Do you have Epilepsy, Hearing problem, DM, Anemia, Dehydration, H TN (Postural Hypotension)?

Pt.: NO

Dr: Do you take medications?

Pt.: yes Dr. I take .... ..... .. (Discuss them with her rapidly they are not related to fall, she takes medications for Arthritis, Osteoporosis, her LMP was 20 yrs ago)

Dr: How are your Sleep, Memory, and Mood?



Pt. they are all fine? Dr.: how is your relation with your family?

Pt.: It is very good; my daughter is very supportive she visits me 2-3 times weekly

Dr: How is your relation with your Mom?

Daughter: we all love her, unfortunately I can't keep her at my home (Can't remember why? may be working)

ADL/IADL

Do General Qs rapidly

Counseling:

Dr: Well Mrs. . . . . 1 do have your case multi-disciplinary report it states that ... ...., There is no acute or urgent health issue to keep you admitted but I need to inform you that in order to be able to discharge you, I must be sure that you will be safe, your safety comes first. Do we have an agreement? Pt. and daughter: Sure we agree on that

Dr: If you want to be discharged home, we can arrange a meeting with outpatient care team, they can help us to assess and adjust your home environment to be safe and avoid repeated falls by: - Put lights on specially during night - Fold all carpets inwards.

-Don't get up from bed rapidly

-Use your contact lenses and have regular visits to your ophthalmologist

-Wear alarm system in case you fall alone you can call for help rapidly - Put a handrail beside the stairs

-Have a frequent (Daily) visits from special nurses to follow you up

Dr: Another option is to write you a letter to one of the nursing houses so they can accommodate you Daughter: it is great idea Mom, you will be safe there and we can arrange the expenses.

Pt.: the money is not a problem I can pay easily from my saving, but I don't want to go there, I am afraid that I will catch respiratory diseases and caught infections.

Dr: I assure you that these nursing houses are very safe, clean and they take much care of their guests and we can arrange a meeting for you with one of these houses just to visit them and have an

Pt.: I will consider this but I am more comfortable with the 1st option.

Dr: -I respect your decision as you are able to decide for yourself. You can take 2 days to think about this and I will be very glad to see you again

-Acknowledge that her daughter is a good person

-Did you understand my plan??? Are you ready to start the plan??

- Your discharge plan includes a team . - Do you have any other concerns? (For both of them)

You are the internal medicine resident on call and your colleague (ER resident) wants to talk with you about a situation in the emergency department

You: Hello my name is Dr..., I am the internal medicine resident on call today

ER Dr.: Hello, I have a concern and I would like to ask for your help and advice

You: Sure, I will try to do my best, how can I help you?

ER Dr.: I have this pt. in the ER, who is known to have borderline personality disorder; she is coming to the ER almost every day, today she is coming with a trial of suicide and cut wrist.

I called the plastic surgery resident to assess her but he refused to assess her this time and he asked me to put a bandage around her wrist. What do you think I should do?

You: (Be supportive to him) I understand your concern, and I agree with you that this is a difficult situation, but to be able to help you regarding this situation I need to ask you some questions about the patient and the situation and together we can figure out a way to resolve this issue.

- Let me ask you first, did you assessed the pt. completely and followed ER and Trauma protocol regarding this type of injury? (i.e.: Iry and 2ry survey) ER Dr.: Yes we did. And she is vitally stable right now.

You: good to know, now let me ask you some questions about the pt. medical history:

I-Disease Q

Since when she have been diagnosed with BPD? Does she take medication? Regularly? Any Investigations? Follow up with Psychiatrist? When was the last time? - -----> She lost follow up with her Psychiatrist Have she been admitted before in hospital? Cause of admission?

2-Scratch Q (current attempt)

How did it happen? When did it happen? Is it the first time?

How many times over the past year? What makes it worse? What makes it better?

3- Suicide Q (SAD PERSONS Q)

Did she do that with the intention of hurting herself?

Did she have plan for that?

Did she understand that it was dangerous for her?

What were you thinking at that time?

Did she take alcohol and drugs at the time?

How did she feel after that?

Is she going to do that again?

Depressed? (MIPASS ECG)

Previous attempts? . ----->YES Suicide in the family ?

Non-support? (Where will she go if she got discharged?)

Sever illness?

5-Specific Q (BPD)

Is she involved in risky behavior like dangerous driving, unsafe sex, or illegal drug use?

Mood changes? Feel hopeless?

Feel lonely? How does she manage that?

How does she feels about your self-image?

Relationship? Child abuse?

6- Psychiatry blocks Q

Stress/affect life? / Screening Qs (Any other psychiatric condition?)

Can I ask you some more guestions about your physical exam?

Description of the wound: length?, depth?, bleeding?

Vascular: Hand color? Temperature? capillary refill? Pulses? (radial/ ulnar) Allen test?

Range of movement: Any tendon injury? -----> Yes tendon is injured

Sensory: Any sensory loss?-----> Yes sensory loss

Motor: Any weakness? -----> Yes +ve weakness

Thank you for providing such valuable information now let's go back to our current situation:

You: Do you know why the plastic surgeon refuses to come?

ER Dr.: He said that he is aware of her condition and already saw her multiple times before; he refused to assess her this time and asked me to put a bandage around her wrist.

You: Any other plastic surgery resident available?

ER Dr.: No

I think this is what we should do (THIS IS OUR PLAN)

1.We should make sure that she is still medically stable

2.We should contact him (the Surgical resident) again to discuss with him how serious is the injury as the pt. might needs admission and surgical intervention, we should make sure that he has full picture of the injury.

3.I can talk to him if you want. He is medically obliged to see her and we are all legally responsible for this patient.

4.If he is still refusing to see her, he has to document that in the chart and you document in the chart as

5.We should file an incident report; contact the hospital management to contact his supervisors to send someone to assess the patient, later on this incident may be discussed at the ethical committee.

6.We need also to consult psychiatry, social service and keep her admitted; We can not let this patient go with cut wrist!!



Musculoskeletal Systems

1. Inspection (expose, compare)

S: Swelling

E: Erythema

A: Atrophy

D: Deformity

S: Scars

2.Palpations

T: Temperature

T: Tenderness

C: Crepitus (passive movement) (l move the joint) E: Effusion

R: Range of motion (active movement) (The patient move the joint)

3.Motor system: pull my hand, push my hand

4.Sensory: you are going to feel like this. When you feel it, say yes. May you please close your eyes

5.Reflexes: Do it on one side and ask I need to compare it on the other side

6.Gait

7.Mention: I would like to examine one joint above and below

8.Special tests

Dermatomes

Sl/S2 = Ankle jerk (Achilles reflex) L3/L4 = Knee jerk

C5/C6 = Brachioradialis/ Biceps

C7/C8 Triceps

Leg sensory supply

L4: medial side of the leg

L5: lateral side of leg & big toe

Sl: little toe

Hand sensory supply

C6: Radial nerve (Back of hand)

C7: Median nerve (Lateral 3 and half fingers)

C8: Ulnar nerve (Median 1 and half fingers)

Level:

C-1

1-+1

C8: C7-T1

OCD

PQRS

MSK

Mechanism of Injury: What happened to you?

Any previous injury

Redness

Swelling

Any trauma

Deformity: Have you noticed any changes in the shape of your joint?

Limitation of movement

Locking of joint, does it give away? (in knee joint)

Noise in your joint

Morning stiffness. If so, how tong does it last?

How does it affect your daily activity?

Weight bearing ability (in lower limb)

Other joints affected

Neuromuscular: Muscle weakness, numbness, loss of sensation

Scleroderma: any skin tightness

GIT: mouth ulcer, difficulty swallowing, change in bowel habits, black stools or bleeding during bowel movements

Urogenital system: penile/vaginal discharge (discharge from penis or your intimate parts), burning in urine, kidney disease

Eye: redness and discharge

Skin rash

General Qs

Management:

1.Investigations

2.NSAlDs

3.Refer to orthopedics

4.Support (Brace....Splint)

5.Physiotherapy

6.Muscle relaxant

7.Avoid lifting heavy objects

Examine the shoulder

1.5 steps

2.Inspection (SEADS) with proper exposure bilaterally and comment about the findings (compare both)

3.Palpation (ITCER) Tenderness at sternoclavicular point, midclavicular point, biceps groove, glenohumeral point, spinou•s process of scapula and medial border of scapula

Crepitus

Effusion

Range of motion

Flexion

Full. flexion

Extension

Abduction

Adduction

Ext rotation and abduction Internal rotation and adduction

Normal range of movement/restriction of range of movement

(Ask the patient to do this & do that, compare both sides)

4.Motor: flexion, extension, abduction, adduction, ext rotation, int rotation

5.Sensory: check above clavicle c4, middle of biceps c5, radial c6, median c7, ulnar c8

6.Reflexes: check on one side & ask for the other side, then compare the reflexes & comment on the reflexes

7.Pulse: compare both sides check brachial artery

8.Special Test

a.Impingement test: Touch the normal shoulder with the palm of affected shoulder and then raise the shoulder from elbow (rotator muscle tendonitis)

b.Jobs Test: Take 2 bottles. Empty the bottle and don't let me push your hand. (Rotator cuff tendonitis)

c.Drop arm test: Place both arms at 1800 and drop it slowly towards your arm. (Rotator cuff tear)

d.Sulcus test: hold hand and then pull it down and look for any sulcus. (For glenohumeral instability)

e.Lift off test: do active internal rotation and adduction and then say push my hand (check for subscapularis tendonitis)

f.Ant. Apprehension test: abduct the arm with 900 flexion at elbow and push it back put the other hand on back of shoulder (for anterior shoulder dislocation)

g.Yergason test: supinate the forearm and try to pronate, tell the patient to restrict it (Biceps tendonitis)

I would like to examine one joint above and one joint below

Case 2 :

33y-old has sudden onset of back pain. Take a history and do physical exam Differential Diagnosis:

Disc prolapse Strain

Facet Joints Spinal Stenosis

Stone in ureter

OCD / Pain analysis:

MSK :

What happened to you? What were you doing when this happened? Any previous injury?

Any redness, swelling, deformity, limitation in activity

Any trauma, noise, how does this affect your daily activity?

Loss of control of bladder and bowel. (Red flag) Any problems with erection?

Fever, night sweats, loss of weight? (Red flag)

Numbness, loss of sensation, weakness

Burning of urine, any blood in the urine. Do you have history of kidney disease?

General Hx (Fhx of prostate Cancer, steroids, stones, drugs)

Examinations

1.5 Steps

2.Inspection: SEADS + Gait including heels and toes

3.Palpation: ITCER range of motion should be flexion, extension, lateral flexion, axial rotation

4.Motor: quadriceps, leg muscle, ankle

5.Sensory

6.Reflex: knee or ankle

7.Pulse: popliteal, posterior tibia', dorsalis pedis

8.Gait: Heel = L5, Toes = Sl

9.Special tests

o Lasegue Signs (l would like to do digital rectal exam)

One joint above and below

CVA tenderness



Investigations:

1.Lumbar x-ray

2.CT scan spine

Indication of imaging:

1.Progressive neurological findings

2.Constitutional symptoms

3.History of traumatic onset

4.History of malignancy

5.Age 25 years

6.Infectious risk such as injection drug use, immunosuppression, indwelling urinary catheter, prolonged steroid use, skin or urinary tract infection

7.Osteoporosis





Case 3

back pain. Patient was helping his friend move 1 week ago. History Taking Tenderness over Para spinal muscles normal motor, normal sensory, (-) SLR tests

His friend gave him oxycodone & he would now like you to prescribe oxycodone

Investigations

Management: Muscle relaxant, physiotherapy, NSAlDs, orthospine referral, avoid lifting heavy objects Diagnosis: muscle strain





60-years-old with back pain. History & Physical Exam

Pain 6 months ago

(-) lean forward

(+) walking down hill

Diagnosis: Lumbar stenosis

Numbness, weakness, cramping, or pain in the legs, feet, or buttocks

The symptoms get worse when the back is stretched or extended, such as when you walk (especially downhill), stand straight, or lean backwards.

The pain gets better when you flex your spine forward, such as when you sit down, lean over a grocery cart, or walk uphill.

Pain in back refers to buttocks and lower limb

History as acute back pain

P/E as acute back pain

The pain often starts slowly. Sciatica pain may get worse at night or After standing or sitting for long periods of time or When sneezing, coughing, or laughing

Diagnosis is sciatica Back pain. Physical exam

Patient has: spine tenderness, (-) straight leg test

Differential Diagnoses:

Muscle sprain, disc herniation, spinal stenosis, osteoporotic fractures





Case 4:

33-year-old with neck pain shoulder pain, hand numbness

Differential Diagnosis:

Disc herniation: neck, arm, hand Stroke: arm, hand

Carpal tunnel syndrome: hand

1.5 steps of examination: look on the table

2.Inspection SEADS: mention: NO congested vein (thoracic outlet syndrome)

3.Palpation TTCER: range of motion, flexion, extension, lateral flexion, rotation on the right and left

4.Motor: Neck, shoulder arm, wrist and hand)

5.Sensation (angle of jaw C2, Cervical Collar C3, above clavicle C4, Biceps C5, Radial C6, Medial C 7, Ulnar C8)

6.Reflexes (Biceps. Triceps. Brachioradialis)

7.Pulses (radial) brachial

Special Tests:

-Spurlings test: Extend the neck turn right and press on his head (+) test is pain

-Lhermitte’s sign: Flex the neck (+ sign) will be electrical sensation in back

I would like to examine one joint below

X-ray of cervical X-ray/lumbar spine:

1.Cervical spine X-ray (anterior posterior, Lateral view)

2.Normal alignment of cervical spine.

3.Narrowing at C6-C7 level suggestive of disc herniation

4.No compression fracture, preserved intervertebral spaces(if x-ray is normal)

5.No osteophytes

WIG

1.Cervical radiculopathy (disc herniation)

2.Cervical myelopathy

3.Axial joint disease

4.Muscle sprain

Investigations

1. X-rays can be helpful in diagnosing neck and shoulder pain.

Plain X-rays can reveal disc space narrowing, rheumatologic disease, destructive lesions, slippage, stenosis, fractures, and instability with flexion-extension views.

2. Magnetic resonance imaging (MRI) is a non-invasive procedure that can reveal the detail of neural (nerve-related) elements.

3.Myelography/CT scanning is sometimes used as an alternative to MRI.

4.Electrodiagnostic studies—electromyography (EMG) and nerve conduction velocity (NCV)—also might aid in the diagnosis of neck and shoulder pain, arm pain, numbness, and tingling.

Knee Examination

1.5 steps

2.Inspection (SEADS) + Gait

No Genu Varum, No Genu Valgum

3.Palpation (TTCER) (Suprapatelar, condyles, tibial tuberosity and patella).

4.Crepitus

5.Effusion in special test...pt should lie down

6.Range of movement, flexion, extension

7.Motor

8.Sensory (14, L5. Sl/)

9.Reflexes (L3- L4) knee reflex

10.Pulses (popliteal or dorsalis pedis and posterior tibial)

11.Posterior knee for Becker's cyst

12.Special test;

Effusion. Lie down PLEASE

Anterior Drawer, posterior drawer for ant and post cruciate (Flex the hip at 45 degree and flex knee at 90 degree sit on patient foot and the hold the knee by both hand with thumbs of both hands touching tibial tuberosity and pull the knee forward first and then backward)

Lachman's test (bend the knee to 15 degrees and pull forward for anterior cruciate ligament)

Varus test (for lateral collateral ligament)

Valgus test (for medial collateral ligament)

McMurray's test o For medial meniscus: flexion, external rotation of foot. Abduction and extension o For Lateral Meniscus: flexion, internal rotation Adduction and extension

I would like to examine one joint above and one joint below Differential Diagnosis:

1.Ligament injury...depends on the special test

2.Cartilage tear

Name the examples from the history that support your diagnosis:

swelling, redness, locking, giving away

Case 5:

33-year-old Mr. Jack Jefferson has anykylosing spondylitis comes to your office perform focal physical examination
or
30-year-old with a history of low back pain for 2 years. He is taking an analgesic. Do a focused physical exam.

1.5 steps

2.Inspection (SEADS) + Gait

3.Palpation (TTCER) Palpate the sacroiliac joint as well. It will be the bump next to the iliac crest

4.Motor thigh, leg, toes

5.Sensory

6.Reflex: Knee or ankle

8. Special test:

a.Occipital-wall distance: stand the patient by the wall and see the distance normally there is no space b/w occipital bone and the wall but it is positive in ankylosing spondylitis.

b.Chest Expansion: Take a deep breath out and measure the chest below the breast on the xiphoid process. Now tell the patient to take a deep breath. Normally the chest expansion in 4-5 cm.

c.Schober Test: Now I am going to draw a line with this washable pen. Palpate both sacroiliac joint and take a middle point of the imaginary line b/w to sacroiliac joint and mark it with pen. Measure vertically from the mark up to 10cm and make a mark at 10cm. Now tell the patient to flex the back. Normally the mark will increase to 15 cm if it is less than 15com then Schober test is +ve.

d.Faber test: Tell the patient make a 4(flexion, external rotation and abduction of knee) with one leg

e.SLR -ve

Lassegue Signs

g.I would like to do digital rectal exam

h.CVA tenderness one joint above and below

Special exams

1.Eyes: redness, discharge

2.Mouth: no mouth ulcer

3.Skin: no skin rash, no tightness, no rheumatoid nodules

4.Listen to aortic area: no murmur of AR

Investigations:

1. X-ray of lumbar spine

Pseudo widening of joint space

Joint sclerosis

Bamboo spines

4. C-reactive protein

Treatment

Anti-inflammatory

Physiotherapy

Muscle relaxant





Case 6:

50-year- old patient comes in for a check-up. Do a hip examination.

5 steps for examination

1.Inspection (SEADS) + Gait + Trendelenberg's test (stand on the affected leg and bend the unaffected knee. The patient will not be able to balance himself and will fall. The test is positive if the hip on the raised side drops. A positive test suggests weakness of the abductors of the other hip.

2.Palpation: (TTCER) all palpation should be done standing

3.Checking for extension of hip when patient is standing

4.Now let the patient lie down and do the range of motion (flexion, adduction, abduction, lateral rotation and medial rotation)

5.Motor system

6.Reflex: knee

7.Sensory system

10. Special test:

Faber test

Thomas test: fixed flexed hip contracture disease:

1.Stabilize opposite of lumbar region of examined leg

2.Flex the hip and knee on the side NOT being tested, and have the patient hold their knee against their chest

3.The non-flexed leg is examined

4.A positive test result occurs if this leg rises off the table, indicating a flexion contracture of the iliopsoas muscle.

I would like to examine one joint above and one joint below





Case 7:

30-year-old man came to ER with one-week history of hip pain.

Vitals: B.P: 130/80 Pulse:105

Temp; 39.5 RR- 22 breaths/min.

Do a focus history_ and PE

a)Septic arthritis. (Migratory arthritis, sore throat, any rash, urinary problem, (Burning of urine, frequency) vaginal discharge. If vaginal discharge COCA+-B and sexual history)

b)Osteomyelitis

c)Reactive arthritis.

d)Crohn's disease. OCD / Pain analysis:

MSK :

What happened to you? What were you doing when this happened? Any previous injury?

Any redness, any swelling, deformity, limitation in movement, trauma, morning stiffness, any

weakness, any loss of sensation, How does it affect your daily activity? Do you have any blood disease such as sickle cell anemia?

Did you recently go on a camping trip? - Do you take an intravenous drug?

Gonorrhea

Sore throat, any rash, urinary problem (burning of urine, frequency) discharge from penis. If discharge

COCA+-B

Sexual history (see gyne)

Abdominal pain

Eye redness /discharge

Lumps and bumps in body

General Qs

Fever/ Fx joint disease

Physical examination

1.5 steps of examination

2.Inspection (SEADS) +Gait+ trendeleburg test

3.Palpation (TTCER)

4.Motor system.

5.Sensory system

6.Reflex



8. Special test o Faber test and

Thomas test. Special exams - Eye (redness and discharge)/ oral thrush/ LN/skin lesions

-Liver/spleen - I need to do genital exam

Investigations:

Name 1 investigation: Arthrocentesis (joint aspirate)

Other investigations:

-Blood culture

-o Gram stain/ PCR of penile discharge

0 CBC/ESR

o X-ray to r/o osteomyelitis

o MRI for osteomyelitis

Treatment:

0 177 of gonorrhea o ITT of osteomyelitis o Organism for septic arthritis: Gonococcal. Chlamydia o Osteomyelitis: Staph aureus/salmonella (sickle cell disease)





Case 8:

25y old jack Jefferson came to the ER with ankle pain after twisting his and do a focus physical exam. OCD+ Pain analysis Specific Qs

What were you doing when it happened?

How did you land on the foot (inversion or eversion)?

After the fall were you able to bear your weight?

Were you able to walk (how many steps (Ottawa ankle rule) <4steps

Any headache, nausea, vomiting and backache.

How did you come here today?

MSK

Any redness, any swelling, any deformity, any blood, any bruise, any loss of sensation, weakness and numbness? When it happened, did your ankle make any noise? How does it affect you now?

General Qs

Family History of joint disease

Physical exam

5 steps

Inspection SEADS+ GAIT (No ecchymosis or blood on the foot)

Palpation: TTCER. 10 points of tenderness (Ottawa rule)

a.Achilles

b.Medial malleolus

c.Lateral malleolus

d.Medial complex ligament (behind the medial malleolus)

e.Lateral complex ligament (behind the lateral malleolus)

6 com above medial malleolus

g.6cm above lateral malleolus

h.Navicular bone

Heads of Metatarsal

Head of fibula

Motor

Sensory

Reflexes (Ankle is easier)

Pulse (Posterior tibial and dorsalis pedis)

Special tests

WIG

Talar tilt (hold the heel and do inversion and eversion)

Anterior drawer test (Put one hand front of lower part of tibia and other on the heel and push the foot forward against the pressure on the lower end of tibia for anterior talofibular ligament)

Thompson test (press the calf muscle, normally there will be plantar flexion but in case there is Achilles rupture then there will be loss of planter flexion

I would like to examine one joint above

What is your management?

X-ray of foot AP lateral

If no fracture: RICE + Anti-inflammatory

Rest

Ice

Compression bandage

Elevation

+ NSAIDS

DD: Ankle sprain, fracture, dislocation, ligament injury





Case 9:

Elbow joint

1.5 steps

2.Inspection (SEADS)

3.Palpation (ITCER) point of tenderness olecranon, medial and lateral epicondyle.

4.Motor

5.Sensory

6.Reflex

7. Special test

Tennis elbow test (extend the elbow feel the lateral epicondyle with one hand and try to restrict wrist extension with other hand)

Golfer elbow test (extend the elbow feel the medial epicondyle with one hand and try to restrict wrist flexion with other hand)

I would like to examine one joint above and one joint below





Case 10:

65 year old female complain of knee pain for 2 years. Take a history and do focus physical exam

OCD+ Pain Qs

MSK

What happened to you? Any previous injury? Any redness, swelling, deformity, how does it affect your daily activity? Any morning stiffness if yes ask how long does it last (this will be the clue for osteoarthritis vs. RA) < or > 30 minutes, trauma, limitation of movement, noise, weakness, loss of sensation

Any skin tightness (scleroderma), any skin rash over face (SLE), and any blood during bowel movement (IBD). Eye pain and discharge (ankylosing spondylitis). Penile or vaginal discharge (Reactive arthritis). Do you have pain in other joints as well (patient may say hand)?

General Questions

Fhx of joint disease. Hx of stomach ulcer disease.

Occupation

Physical examination (knee)

1.5 steps

2.Inspection (SEADS+ Gait)

3.Palpation (ITCER)

4.Motor

5.Sensory

6.Reflex

8.Special test (All)

9.Special examination:

Eyes (redness, discharge)

Mouth (no mouth ulcer)

Skin (no skin rash, no tightness, no rheumatoid nodules)





Case 11:

Physical exam of hand

1.Inspection SEADS (mention about bouchard nodes and heberden nodes)

2.Palpation (TTCER): wrist and fingers

For range of motion do flexion, extension, ulnar/radial deviation of wrist

Spread the fingers a part, do the opposition of fingers.

3 . Motor: wrist and fingers

4. Sensory

5 . Reflex

6. Pulse (radial)





Case 12:

Pain in toe

History:

OCD

PQRS

Same system questions: swelling, redness, deformity, noise, trauma, affect daily activity, limitation of movement, morning stiffness, weakness, loss of sensation, skin lesions, skin tightness, difficulty in swallowing, diarrhea, constipation, bleeding from bottom, kidney disease, Penile discharge, burning in urine, red eye, eye discharge

Ask for kidney stones: blood in urine, flank pain, stones

Risk factors: Diet, obesity, coffee, hydrochlorothiazide, family history, alcohol

WIG

General questions: fever...Who do you live with?

Physical exam:

5 steps

SEADS

ITCER

GAIT

MOTOR

SENSORY

REFLEX

PULSE

CVA tenderness

Diagnosis: Clinical

Synovial fluid analysis: monosodium urate (MSU) crystals in synovial fluid

X-ray

Serum uric acid

Treatment:

Acute attack:

I. Naproxen 825 mg once/day /or Indomethacin: 50 mg tid

2.Colchicine 0.6-1.2 mg

3.Prednisone 20-60 mg oral

Prevention of the attack: between the attacks

1.Probenecid 250 mg twice daily for one week

2.Allopurinol 300 mg/day

3.Avoid thiazide, control diet and weight

Laboratory:

1.Serum uric acid

2.Arthrocentesis and joint fluid analysis

3.Renal function test





Case 13:

Case: Hand pain after fall. X ray is normal

Fractured scaphoid

Physical examination:

5 steps

SEADS, TTCER

Motor, sensory, reflex, and pulse

Special test (anatomical snuff box pain)

Investigations: repeat x-ray after 10 days

Rx: short arm thumb spica [10 days]





Case 14:

17 years old with knee pain with tenderness on tibia' tuberosity (Osgood-Schlatter)

X ray (soft tissue swelling over tubercle, fragmentation of the bone on TT)

Rx:

1. Reassurance

2. Restriction of activities.

Patient may say: I have to do sports:

Answer:No, restriction of the activity for 12 months

3. Aerobic exercise (strengthening of the muscles).

4. Anti- inflammatory medication





Case 15:

60-year-old female with fatigue and malaise Take a focused history.

How can I help you?

--> Pain in multiple sites (pain in neck, upper arms, buttocks, hips & thighs) Which bother you most?

---> Pain around my shoulder (Pain in shoulders, often the first symptom)

OCD: within two weeks

PQRS



MSK

Stiffness > 2 weeks in affected areas, particularly in the morning improve as the day proceeds Limited range of motion in affected areas

Specific questions

Loss of appetite

Wt losss---> yes

Depression

How does that affect your life?

Sleep disturbance

Any headaches, vision difficulties, jaw pain (Giant cell arteritis)

DD of fatigue: Anemia, thyroid, medications, DM, fever, Depression

General Questions:

Diagnosis: Polymyalgia rheumatica

Criteria: > 60 years, proximal muscle myalgia, pain & stiffness in joints, no muscle weakness, +++ESR, low grade fever

Investigations to diagnose and to rule out other differential

ESR (one investigation) CBC

C -reactive Protein.

U/S and MRI

Thyroid profile

FBS

Treatment

o NSAIDS

oLow-dose corticosteroids. (Prednisone orally: 10 to 20 mg/day).

o Relief from pain and stiffness should typically occur within 48-72 hours, if a patient doesn't improve within 3 days other diagnosis should be considered.

After the first two to three weeks of treatment, prednisone should be tapered gradually to the lowest dose to control Sx, and treatment should be continued for 1-2 y
 
Please note that this is only a draft version based on Dr. Basel Mohsen’s lectures. Edited and organized for the sake of all attendances of the Canadian Osce Exams: NAC OSCE and MCCQE2. 2010/2011.

WARFARIN COUNSELLING

WARFARIN COUNSELLING

40 M came to clinic as he was informed by clinic to come as his INR result was 1.
Next 10 mins take history & provide counselling Divide into 2 parts:

1. History ------> 5 mins

2.Counselling ------> 5mins

General scheme:

1.Event

2.Symptoms at the time of prescription

3.Compliance

4.Risk of bleeding from other sites

5.R/O relapse of DVT

6.Drugs and diet that interfere with warfarrin: Grapefruit,
Antibiotics, NSAIDs, Antifungals,

Restart INR (fresh person)

X3 dose of 10mg/d  change INR every day
(change the warfarrin accordingly)
Check three time a week the INR if three consecutive are in the
goal range  once aweek  than for every two weeks check once
 than every month (or depend on the condition) If INR>10 or patient is bleeding
 Vit. K (if active bleeding give FFP according to setting)

Greeting: Good afternoon Mr.Hendricks,I’m Dr.X with you & will be your physician for today.
As I understand, you’re here to discuss your blood reports.

1.Why was the blood test done?

[Pt had DVT x 5 wks ago,& was having regular checkups
till last week when he decided to stop as he’d read
some alarming information on the internet & did not like warfarin
(or other scenario,his friend who was on warfarin had a stroke)]

2.When was DVT Diagnosed?

3.How was it diagnosed?

4.What was done??

5.WAS HE TREATED AS AN OUTPATIENT OR WAS HE ADMITTED?/If Yes: How many days?

6.What were the symptoms at that time?

7.Was there pain & swelling?

8.Was there SOB (lung involvement)

DO NOT LOOK FOR FACTORS THAT CAUSE DVT

9.Which medicines were you treated with? -----> Blood thinners/Warfarin?

10.Is INR done on a regular basis?

11.What was the last time it ws done?

12.What was the target?

13.What was the level?

NOW BREAK THE NEWS

Your INR is ONE; do you know the reason why?

IF Pt vague, give him options:

1...Do you take your medications on a regular basis?

1.Do you take your meds by yourself or do you need help?

2.Any chance you were skipping a dose?

3.Did you start any new medications or antibiotics?

4.Diet: Are you eating a lot of spinach?

5.Any Vit K supplements?

[If Pt expresses concern about bleeding S/e:Adress it & say it is a reasonable enough concern.
I’ve to ensure that you do not have any bleeding at that time.

Did you notice any blood from your gums,nose,bruises in body,coughing up blood? Neuro Sx:.....

Since you stopped the meds, I want to ensure that there is no Relapse of your DVT:

Do you have: Swelling/Calf pain/SOB/Heart racing/Chest tightness? 2 Qns about PMH:

H/o long term illness or surgery

FH

COUNSELLING:

What is your understanding of DVT?....clot

Why did it occur? .......

The concern about this clot is that if not treated,
there is a chance of relapse, or it may recur & this chance is: 8%

To decrease this chance to 0.8% we use warfarin

If DVT occurs more than twice – take life time medication.

If not convinced: In addition to local recurrence there is
damage to veins in the legs& valves& if this happens more than once warfarin has to be taken for a longer period

In addition these clots formed in your legs
may dislodge & travel all the way to your heart,& This is serious.
If large, can cause, sudden death. Can travel to lungs & can cause a condition
called PE which again is a very serious condition

Of course the main side effect is bleeding which is
very rare if properly monitored. As long as INR is in normal limits chances of bleeding are minimal i.e: 1%

We’ve to restart with Heparin & warfarin & monitor INR on a daily basis

 

 

EPILEPSY COUNSELLING



Young 16 yr old male for driving License counsel

Always ask Qn as to why he wants a driver’s license. Usually a Dr does not give such a note unless there is an underlying condition.

General scheme:

1.Intro

2.Event – before in and after the attack. When was the drug level checked?

Any other medications that might interfere with epileptic drugs (e.g. OCPs).

3.If it is only seizure  go to secondary causes of seizures  refer to neurology 4.Which medication, and compliance

5.HEADDSSS –

6.Triggers – sleep deprivation

7.MOAPS

8.Counsel: needed to be seizure free for one year. Invite him again for f/u after one year. Risk behaviour: drivint, swimming, hicking, bath door open and don’t take bath but can take shower, no heavy machines

You have to take it for your whole life – if you have any attack let me know and we’ll discuss it. Talk with your physician about any new medication you want to take.

Valproic acid 500mg.

OCD:

1.Age of onset

2.When was the Ds

3.What was the Ds

4.How long does each attack last?

5.How frequently do the attacks occur?

6.+/- LOC

7.Aura prior to attack

8.How does she feel after the attack?

9.What meds is she on/Is she compliant/Were the drug levels checked? 10. Any other meds (if female ask about OCs)

11.When was last attack?

12.What happens during an attack? Does she shake/All over/Partly/roll up her eyes/bite her tongue?

I’ve to ask questions to R/o any new pathology:

System review:

CNS: Head trauma/HA/Vi

CSx:

MOOD: Any chance you may hurt yourself?

PMH: h/o Dm

HEAADDS

HOME: With whom do you live/How is your relationship with parents/siblings

EDUCATION: How is school? How’re your grades? Any recent change in grades?

ACTIVITIES: what are your hobbies?

ALCOHOL: Sometimes kids your age might smoke or take alcohol & experiment with drugs, any of your friends do it? How about you?

If YES: How much/How often?

DIET: How is your diet?

DATING: Are you dating? Are you sexually active?

STIMULANT USE:

STRESS:

SLEEP: Do you have enough sleep?

MAKE SURE that he knows what a seizure is

What do you know about epilepsy?

It is a common condition due to increased electrical activity in the brain, some people lose consciousness, and some do not. It does not cause learning disability or damage the brain In those who have seizure attacks:

If lasts for a few minutes there is no brain damage

If lasts for > 30 minutes, will cause brain damage

People with epilepsy should AVOID dangerous activities such as:

1.Driving

2.Mountain climbing

3.Swimming

4.Operate machinery

5.Boating

6.Chewing gum

7.Tub baths (have a shower bath & never lock bathroom door)

You can have a driver’s licence only after you’ve been seizure free for 1 year It is my duty as your physician to inform the Ministry of transportation

Mention TRIGGERS

•If you drink alcohol, it decreases the point at which ea seizure occurs and can cause an attack

•Sleep deprivation also can cause it

•So also flashing lights

If you want to take any other meds, speak to your Dr

I will check the blood levels of your medications to see if it is at the therapeutic level If you want to get pregnant consult your Dr

There are support groups

Regular F/u Any

Concerns?

OCP COUNSELLING



21 F for OCPs Counsell x 10 mins

General scheme:

Intro:

Good morning xxx,I’m Dr...... As I understand,you’re here today because you want a prescription for Birth Control pills.

During the next few minutes, I will ask some questions that will help me

Questions here:

1.Have you ever used any form of contraception before ?

2.Why do you want to use it?

2.1.If in stable relationship

2.2.If sexually active

2.3.Do you practise safe sex?

2.4.How do you feel about this relationship?

2.5.Prior to this were you in any other relationship?

2.6.Whose idea was it/ Yours or His?

MGOS

MENSES:

MENSES Use the word ―period‖

1. When was your last period?

2. Are your periods regular / not 3.

How often?

4.How many days or How long does it last?

5.How many pads do you use/change?

6.Are the pads full?

7.Are they heavy?

8.Do you see clots?

9.Between periods do you have spotting?

10.From your last menstrual period was your period different from the current one?

11.At what age did you start your periods?

12.Were they regular/irregular?

13.When did it become regular?

14.Are your periods painful / painless?

15.If irregular from beginning?

16.Discharge – ask if pregnant and when LMP

GYENECOLOGY

1.Any history of Gyn. Disease – polyps or cysts 2.

2. History of pelvic surgery (if yes – when?)

3.Have you used any birth control?

4.When/type/any complications

5.Pap’s smear

OBSTETRICS:

Have you ever been pregnant?

Have you ever had an abortion or miscarriage?

SEXUAL HISTORY:

Any STIs?

Any PIDs?

Any partner with STI?

CONTRAINDICATIONS:

To find out if you’re a suitable candidate,I need to ask a few more

questions: ABCD (Active liver disease, Bleeding, Cancer, DVT) 1. Any abnormal vaginal bleeding?

2.Any active liver disease: (Ac & Ch)

3.CVS:Have you ever had clots in your calves/DVT/Very High blood pressure

4.H/o Migraine headaches?

5.FH of Ca breast/Uterine or Liver

AGREE to give if No CI

EXPLAIN what are OCs

1.Combination of hormones Estrogen & Progesterone or sometimes only a progesterone

2.These come in packs of 21 or 28 pills

3.They prevent pregnancy by interfering with hormone signals in our body & prevent ovulation

4.Also make the inner lining of the womb & makes it hostile for conception

5.Thickens secretions at the mouth of the uterus & prevents conception

MISSED PILL;

To be taken at same time every day, so chances of forgetting is less & constant blood levels

1St pill on 1st Sunday of period, or 1st day of periods

1st month use back up method of Cx like a condom

In first 2 weeks:

If miss one pill: Take 2 pills next day & use condom x 1 week

If miss 2 pills: Take 2 pills same day + 2 pills day after + Condom x 7 days

If miss 3 pills: Stop,use condom & restart new pack In 3rd week:

If you miss any pills restart new pack

Explain BENEFITS:

1.Help regulate cycle if periods are irregular

2.Will eliminate pain

3.Less blood loss during periods

4.Less chances of benign breast disease & ovarian Ca

But like any other medications, there are also the SIDE EFFECTS:

•MILD

N/V,Wt gain (5lbs)breast heaviness,mood changes,Spotting may occur in the initial months If these occur,you can change brand

•SEVERE;

Severe Ha/SOB Chest pain -----> If these occur STOP the pill & sek urgent medical attention DRUG INTERACTIONS:

If takes any other medications,let her Dr know she s on the pill

SAFE Sex:

PAP’s Smear

If Teenager: HEAADDS

Last any Concerns or qns?

ABORTION



1.Young woman 19 yrs asking for abortion x 10 mins counsel

2.Can be a teenager with a vague complain

a.Read body language & assure Confidentiality

b.When did sexual contact occur?

c.Who was the partner?

d.Was she raped or was it against her will?

e.Is she being regularly abused?

f.Do her parents know?

M (Signs of pregnancy: engorgement of breast, urine frequency, n&v)

O

G

S

PMH

SHx:

HEADDSSS:

Home enviorenment & parental attitude

MOOD & Interest SUICIDAL IDEATION NOW?

When pt tells outright she wants an abortion:

How do you feel about having an abortion?

If she says she feels there is no other option:

Explain that there are other options, Do you want to know them?

When did she find out she was pregnant?

Here be sensitive if she found out last night, she is probably in a panic, but if she has known it

for a week, she has thought about it well, & is more decisive.

Before it can be done, I need to ask you some qns

1.How did she find out she was pregnant?

2.Was she using any contraception?

3.Has she spoken to her partner/family/friend?

4.Would she like to talk about it?

LMP: How was her LMP, was it similar to her previous LMP? Or was it shorter, lighter?

Is there Nx/V,visiting washroom more frequently?

Breast engorgement?

O

Have you been pregnant before?

Have you ever had an abortion/miscarriage?

G

Has she ever used any kind of birth control before?

Any Pelvic surgeries

Any Pap smear (depending on age)

H/O STIs

Since it is the first time I’m seeing you, I need to ask about

PMH;

Any H/o HTN/Liver disease/DM?

Surgeries/Anaesthesia complications

Blood Group

Any Medications/Allergies

SOCIAL Hx:

With whom do you live?

How do you support yourself financially?

If young teen: HEAADDS

Whatever you choose to decide, I will support you. Is she decides to go in for an abortion:

I will refer you to an abortion clinic

However it is difficult to get an obstetrician who will do it after 20 weeks

She has to make a decision fast

Also here ask about her own support system (family/boyfriend)

I will also get you connected with a support group, who are women who’ve had abortions before & will help you cope with it.

Now in addition to abortion there are OTHER OPTIONS:

Would you like me to tell you about them?

1.If your concern is financial, you can carry on this pregnancy & there are a lot of support groups as well as the government who will help you.

2.You can carry on this pregnancy & give up the baby for adoption, a lot of people are looking for a child also nowadays you can have visitation rights in certain cases.

If Pt is still going for an abortion:

For now, I will do

1.PAPs test

2.Blood tests: Sr B HCG & Blood group & Rh typing

3.Ultra Sound

Once your pregnancy has been confirmed by us, I will send you to the abortion clinic From now, until the time you’ve the abortion, you’ve to;

Quit Smoking/Alcohol/Drugs

If you happen to see any dr during this time period, you’ve to inform him you’re pregnant

Smoking Cessation



According to the type of patients we will allocate the time:

Neutral: Hx (4m), Why (3m), How (3m)

Willing: Hx (4m), Why (1m), How (5m)

Unwilling: Hx (4m), Why (5m), How (1m)

General scheme:

1.Intro (“Very good decision”)

2.Hx

2.1.Impact: breathing, coughing, phlegm

2.2.RF: HTN, DM, Hyperlipidemia,

Questions about target organs: heart, lung

2.3.Gain from quitting: what do you think you are going to gain from quitting 2.4. Hx from previous quit – what support do you need? What led to relapse?

Withdrawal symptoms? What is the longest time you quitted?

2.5.In which situations you need to smoke?

2.6.SHx: do you smoke in front of your children?

3.Counseling

What is your motivation to stop smoking (scale 1 to 10)

Different people from different reasons…what is the reason for your smoking?

3.1.Why

3.1.1.Effects of the smoking on different of the body

3.1.2.Reduced risk for diseases – time frame

3.1.3.Influence on other household

3.1.4.Economical effect

3.2.How

3.2.1.Set a quit date within 2 weeks – reduce gradually within 2 weeks

3.2.2.The support you’ll need – tell your family. Found someone who wants to quit.

3.2.3.Diary

3.2.4.Exercise, healthy diet

3.2.5.Things you can do instead of smoking

3.2.6.If taking nicoting replacement – stop smoking.

3.2.7.Medication: Ziban (bupropion) 150mg (only in the morning for three days and than increase to bid to 7-12 weekly up to 6months)

S/E Insomnia and dry mouth

C/I seizure, eating disorder, MAOI;

Varenicline (Champex)

S/E nausea

C/I Previous psychiatric conditions

Intro

Hello Mr./Ms. …..

As I understand you are here today to seek help to quit smoking. I am really happy to hear that – can you tell me what made you come to that decision?

What are your expectations from this visit?

Motivation can be assessed by asking the following two questions:

1.“Given everything going on in your life right now, on a scale of 1 to 10, where 10 is the most important thing to do right now, how important is it for you to quit smoking altogether?”

2.“Given everything going on in your life right now, on a scale of 1 to 10, where 10 is the most confident you have felt about anything, how confident do you feel you will be able to quit smoking altogether?”

Ask about the smoking now – how long, how much, since when Impact of smoking of his life: breathing and coughing, weakness, relationship and sex, CSx RF: HTn, DM, Cholesterol, FHx of CAD and Cancers,

In your opinion - what are the good things you will gain from quitiing?

Have you tried to quit before?

What stopped you from quitting before?

What support will you need in order to quit?

What are the situations in which you usually smoke?



Smoking Hx

What is the reason that made you decide to smoke? How much you smoke, how long (More than 10pk/y -

Because you have been smoking for long time I’d like to see how this smoking has affected your health:

Target organs: Heart, Lung, GI, PVD, Sexual,

CHx

MOAPS

FHx (also addiction, cancer, suicide, depression)

SHx

Do you smoke in front of your children?

Counselling

Why

Different people smoke from different reasons - what is the reason you smoke?

In your opinion – what are the advantages of smoking?

Do you know what the active components in cigarettes are? (It is Nicotine, and when you smoke it you have a sense of well being. To maintain the same effect you keep increasing the number of cigarettes and by that tolerance develops. So, when you stop you get withdrawal symptoms, and therefore it is habit forming and difficult to quit. In addition to the effect on our brain it causes narrowing of our blood vessels all over the body.

In the heart it causes heart attacks which are leading cause of death in our society.

In the brain it causes stroke which is the third leading cause of death.

In the GI it causes peptic ulcers.

It can cause erectile dysfunction.

In addition to nicotine, cigarettes can contain few thousands of other substances – some of these affect the lungs and cause COPD which is an irreversible condition which there is no treatment.

On top of that, smoking is associate with cancer in a lot of different organs of which lung cancer is the leading cause of death from cancer worldwide.

In addition to medical impact it affects also family members and expose them to most of the harmful effects mentioned previously.

It is expensive, staining and smelling, increases hazards (fire).

If you quit smoking you are taking the right step and can expect to gain the following:

• After 1 year, the risk of coronary heart disease is cut in half

• After 5 years, the risk of stroke falls to the same as a non-smoker

• After 10 years, the risk of lung cancer is cut in half and the risk of other cancers decreases significantly

• After 15 years, the risk of coronary heart disease drops, usually to the level of a nonsmoker

How

1.Set a quit date. It should be within the next two weeks. Avoid a time when you will be under stress.

2.Think about why you want to quit and all the good things that you expect as a result of quitting.

3.If you have tried to quit before, you have probably learned some valuable tips of what not to do this time. Think about what was most difficult last time and why you gave up trying. Think about the things you need to avoid this time.

4.Decide what kind of support will be most helpful over the next six months to a year. For example, you can join a smoking cessation group or plan to meet regularly with a health professional (such as a pharmacist, nurse or doctor).

5.Tell your family and friends that you are quitting. Ask them to help you to stick to your plan. If they smoke, ask them to respect your decision to quit and to not smoke in front of you. Think of things you can do to avoid smoking while with them.

6.Find someone you know who does not smoke and ask them to help you to quit.

7.Make a diary for a few days to keep track of when and why you smoke.

8.Think of ways to avoid situations when you usually smoke.

9.Buy a brand you don’t like. Buy one pack at a time. Increase the time of lighting it, and smoke only part of it.

10.Think of things you can do instead of smoking (for example, chewing gum, sipping water, holding a fake cigarette).

11.Most people gain weight while quitting. You can avoid this by healthy eating and increased activity. Keep healthy snacks around for times when you get the urge to nibble.

12.Keep busy with healthy activities like walking or an exercise program. Starting a new activity will help to break old habits connected with smoking.

13.If you are taking medication to help you to quit, be sure to follow the instructions carefully.

14.If you are taking nicotine replacement therapy, do not continue smoking, as this is very dangerous to your health.

OBESITY COUNSELLING



38 YOM 6 ft height,weight=260Ib 10 min.HX. and Education Keys:

•Explore motivations for wt.loss.

•Provide information about the consequences of obesity (health and psychological wellbeing) and nutrition.

•Set realistic goals, target BMI

•Offer support/reinforcement throughout the weight-losing process. Hx

DIET & EXERCISE:

Motivation for losing wt. now?

Self –image,

Health concerns? ……… Can

you tell me

more. Good decision to come today, I am glad you came.

If patient request first surgery, tell him that sound reasonable however, surgery is not the first line can be done based on BMI if >40 If you like I can calculate it for you; kg/m2.

I need > information about your condition:

WEIGHT:

1.What is your weight today?

2.Highest weight.

3.When started to gain wt?

4.When started to be concerned?

5.Have you tried any wt- loss programs?

6.Which one?

7.How long?

8.Did you lose wt?

9.Why did you stop?

I am going to ask you Qs to see

WHY YOU’RE GAINING WEIGHT:

Do you calculate your calorie intake?

How many meals do you take/day including snacks?

Tell me more about your DIET:

•What do you eat?

•How much fat, fruit, veg bread?

Eat while watching TV,

Before bed,

Breakfast daily,

Ever eat to relax or when stressed?

Binge eating?

Do you feel guilty about your eating?

Do you induce vomiting/purging?

ALCOHOL

How about your ACTIVITY, Do

you exercise? IMPACT:

I am going to ask you how this Affects your life?

1.Difficulty sleeping,

2.Tiredness,

3.Heart burn,

4.Nausea, vomiting,

5.GB stones, bowel motion, 6. Back pain,

7. Jt pain.

PMH: HTN, DM,

Medications: anti-psychotic, OTC, steroids, thyroid disease, OCP.

Social Hx: With whom do you live? Any change in sexual desire?

How it affects your self esteem,mood and interest?

Do you smoke? Drink? Recreational drugs?

FHx : obesity Education:

There are some genetic factors that influence wt. We can’t modify these but we can modify our diet and exercise. In some people, diseases are the underlying cause for obesity.

Give patient their ideal wt. for ht. >20% ideal wt is obesity.

Being overwt increases the risk of

Hypertension,CVD,CAD,GB disease,DM,fatty liver,cancers(breast,bowel),OA,sleep apnea,spinal dysfunction.

• We recommend to lose 10% of your body wt.over 6 months (gradually).guidance is BMI

There are 2 methods to lose wt: Decrease intake or Exercising more.

If you like I can refer you to a dietician.

We also recommend dividing your meals into 3 small and in between snacks ( carrot, veg.or fruit) 55% CHO, 15% protein,30% fat Avoid saturated fat, cheese, alcohol Give patient a target caloric intake: to lose 1 Ib/week,should take 300-500 kcal less 1g fat-9kcal, 1g CHO-4kcal, 1g protein-4kcal

Do not recommend diet medications and fad diet, these may be harmful and are of no long-term benefit. If BMI>27 + RF (DM, Htn...) or BMI > 30 start pharmacotherapy:

Xenical=increase bulk of stools, leakage, decrease absorption of fat sol.Vit.

Meridia (sibutramine) = suppress appetite, cause heart racing, hypertension.

IF BMI>35 + RF or BMI > 40 recommend Baratric srgery

Exercise:begin with walking,regularly 30 min,4-5 times per week

Reach 60-80% maximum heart rate (220-age)

Self-monitoring, group support

Follow-up: advise patient to come back in a week with food intake diary

70 yr old female with H/o fall at home .Brought in by ambulance personell to the ER. She is medicaly cleared; In the next 20 minutes take history & Counsel;

Diff/Diag (Dd): 1.Poly pharmacy 2. Recent hypovolemeia •Diarrhea/Vomiting •Lack of intake •Recent bleeding 3.Orthostatic hypotension 4.Hypoglycemia 5.Elder abuse FALL: 1.When did the fall occur? 2.Where did it occur? 3.Were you alone? 4.Could you get up by yourself or did you need help?

5.How long before you got help?

6.Did you trip or just feel your legs give way?

7.If there was a witness around ask permission to speak to witness after you finish talking to Pt to obtain collateral history

3 parts of history relating to the EVENT:

A.Before fall

B.During the Fall

C.After the fall

Events assoc with the Fall: A.Before:

1.Did you feel

2.Light headed/ Spinning/ Hungry/ Heart racing & Sweating --- HYPOGLYCEMIA

3.Chest pain/ Palpitations/ Shortness of breath----CVS

4.Lights flashing/ Strange smell/ Strange feeling in body--Seizure

5.Weakness/Numbness/Dificulty finding words/Visual disturbances --CNS/STROKE

6.Was the lighting good?

7.How is your vision

8.Is your footwear comfortable?

B.During the Fall:

1.Did your wife mention that you were shaking or making jerky movts?

2.Did you wet yourself?

3.Turn blue & were stiff?

4.Bite your tongue?

C.After the fall:

1.Nausea/Vomiting

2.Weaknes

3.Difficulty finding words

4.Any vision difficulties

5.Loss of sensation in the arms or legs

6.Ringing in ears

Has this ever happened before

1.When & where

2.Did you seek medical help then

3.What were you advised?

CONSTITUTIONAL SYMPTOMS:

•Fever & Chills & Night sweats

•Wt loss & Loss of appetite

•Lumps & Bumps

Sx related to CVS:

Chest pain/SOB/Palpitations

Sx of CNS:

Weakness/Numbness/Loss of vision/LOC

Past Medical History;

1.Are you taking any medications?

2.Can you take them by yourself or does your caregiver give them to you?

3.Do you take them regularly as prescribed?

4.Can I see them please?

Please see the meds

Was there a recent change in the meds

5.Besides these do you take any additional OTC products or herbal medications?

6.Do you take alcohol? ..............

•How much do you take regularly?

•Did you take alcohol prior to the fall?

7.Do you have high blood pressure? • When was it last checked?

• What did your doctor have to say about it?

8.Do you have high blood sugar or Diabetes? • When was it last checked?

• What did your doctor have to say about it?

9.Did you ever have a stroke or heart attack?

10.Were you ever diagnosed with Cancer

11.Were you hospitalized at any time in your life?

I need to ask a few more questions concerning your lifestyle that will aid me to help you.

It is all confidential & my duty is to help you (When you suspect Elder abuse)

1. With whom do you live?

2.Are you happy living with XXXXX

3.Who prepares your meals?

4.Do you do your own shopping?

5.Do you manage your own finances?

6.Do you go out of the house & meet up with friends & have your own social life?

7.Do you get into arguments with XXXX?

8.Have you ever been hit or yelled at or threatened by XXXX?

COUNSELLING FOR POLYPHARMACY (Orthostatic Hypotension)

Based on what you’ve told me most likely the reason of your fall is a condition called “Orthoststic Hypotension”.Have you ever heard about it?..........

When you change position from lying to sitting or standing blood pools to the legs & Bld vessels narrow to maintain BP.

In pts with OH because of Age,Medications,DM or a combination of these condts body might fail to react,& blood pools in the legs & thus BP drops & there is not enough bld reaching the brain.

There is a possibility that this might happen again & from now on whenever you change your posn from lying get up slowly,sit at edge of bed & slowly get up.

I need to get in touch with your doctor & modify the dosage of your meds or change them. Is it alright with you?

I need to talk now to your wife & do an ECG to check your heart

HA DOMESTIC VIOLENCE

Domestic Violence common presentations:

1.HA

2.Abd Pain

3.Ac Abd

4.Insomnia

5.Sleeping pills

6.Vaginal Bleeding

Sx

1.No good eye contact

2.Vague complaints

3.Non communicative

OCD/PQRST

CONSTITUTIONAL Sx: R/o Migraine & Tension HA RISK FCTS:

Smoke/Alcohol/Recreational drugs

PMH:Are you on any meds/OTC/Herbal meds?

Were you hospitalized at any time?

FH:

SOCIAL HISTORY: Important**

All information you give here is entirely confidential & will not be released unless you authorize it Who lives with you?

Any recent changes/Stress in your relationship SCREEN FOR DOMESTIC VILOENCE:

Does your Partner:

1.Hit you?

2.What happens during an argument?

3.when he is angry,does he :

4.Shout/Swear & call you names or demean you?

5.Has your partner ever ridiculed you or cut you off from other relationships with friends/family?

6.Have you ever sought help from others in health care? ABUSE RISK FCTS:

1.Drink alcohol,drink more now than before?

2.Does he have access to firearms?

3.Does he ever get angry to the point where he gets

physical & hits you?Did you ever have to go to the ER? Was there a serious consequence?

4.Are you having more arguments now

5.Does he get more angry now,& How has all this affected your self esteem?

6.How does it make you feel?

7.Does he ever force you to have sex against your will?

8.Who controls the finances & spending?

9.Has he ever mistreated you in front of the children?

If yes: it is emotional abuseto children & has to be reported to CAS

10.Has he ever misRxed th children?

11.Have you ever thought of putting an end to your life or his life?

Have you spoken to anybody abt this?

Do you have some support?

COUNSELLING: Empowering & Education

3 kinds of Pt:

1.She wants Help

2.She might Consider getting help

3.She does not want to get help & thinks he is right

I’d like you to know that what you’re experiencing is called “Domestic Violence “or Spousal abuse.

It is a crime against the law & not acceptable.

It is not your fault & you should not accept it & feel guilty

It can get out of hand & you can get harmed seriously

Call Police (Never Call Police from your office)

Contact Social worker, who will help you with housing, finding a job & finances & child support If she is considering

Escape Plan

Keep a bag with important documents,change of clothes & hide it

DOCUMENT

Fup x 3 days

 

Diabetic Daughter 2y, Counsel



Either she is not doing well in school

Not seeing well

Not playing well, tired

DKA

Is it regular f/u or something special you wanted to discuss?

When was the last f/u?

How was she diagnosed?

What happen then?

What were the symptoms?

Is there any pain / vomiting?

Are you feeling eating/drinking/peeing more?

Is there any weight loss or blurred vision?

From the last f/u till now have you had DKA? How about before?

Have you had low blood sugar?

Talk with the father: which medication does she take? How does she take? When was the last time?

Do you take insulin or somebody else gave it to you?

Do you take it all the time?

DO you skip dose?

Does she need any help to take insulin?

DO you measure blood sugar regularly?

When was the last time? Do you record them in the machine?

(The glucometer should be used by only one patient).

There is a blood work called ―Hemoglobin A1C‖

it is done every three month – did you do it?

Did you start new medication? How about your diet?

DO you have your log book?

What do you eat?

Have you ever seen by a dietician?

PMHx

FHx

Counseling A lot of people have diabetes and she is not the only one.

What’s your understanding of diabetes?

Whenever we eat food contains sugar it is absorbed in our stomach and goes to the blood and from there to different parts of our body.

Sugar act in our body like a fuel, in order for our body to use this energy it needs insulin.

Patients having diabetes have not enough insulin. Sugar will be built up in your blood. The body tries to get rid or it, by peeing extra sugar – this will lead to thirsty and tiredness. This can be avoided by controlling the blood sugar.

If you control your blood sugar you’ll be able to play again.

If not controlled – may end in DKA, hypoglycaemia and serious consequences.

Always be aware of hypoglycaemic symptoms: loss of conscious, sweating, heart racing, hungry.

Since you might lose conscious it is important to carry MedAlert Caed or Bracelet which will clarify your situation.

Medical Error, Wrong blood transfused

When there is a mistake, always there is a kind of unintentional medical error.

(to the nurse) when informed about wrong blood – ask:

―did you stop the blood?‖ say: ―Well done!‖

If she asks not to tell the patient...ask her what her believe she may loose her job, and it is too early to determine who is responsible.

Errors take place in medical practice. We don’t know what exactly happened.

We will stabilize patient and ensure he’s fine and later deal with this issue.

(to the patient) Intro: I am the doctor in charge, and it looks like it was an unintentional medical error took place. We need to make sure you are stable. We don’t know who is responsible, there are at least 15 steps and in each step could have been an error.

We will fill an incident report and as soon as we get result we will inform you. You can sue, it is your right at the moment it is my priority to stabilize you.

ABCD

A – Open your mouth (check for anaphylaxis, no swelling in mouth, ask for any itchiness, or difficulty breathing), Oxygen saturation.

Normal air entry.

Normal S1, S2

Vitals again

Remove blood unit and keep cannula. Start new IV line.

Once new line, don’t give fluids if stable.

Send blood: CBC, Lytes, INR, PTT, LFT, Cr, BUN, FDP, Haptoglobulin, Direct coombs test; Urinalysis: hemoglobulinuria

Unit to be sent to blood bank for cross matching.

Ask nurse to call the blood bank and keep original blood.

D

D1 – I’d like to shine a light in your eyes. Pupils are round, active, and symmetrical. Squeeze my finger, wriggle...wriggle... D2 – (if febrile) give tylanol Please prepare for me benedril (Diphenhydramine) 50mg. Steroids (Hydrocortisone) and Epinephrine Secondary survey

Hx (two parts:) condition (how is he feeling now) and the other is: ―Why blood was given?‖ Condition: Do you feel warm? Chills? Itchiness? Tinglings? Diffculty breathing? Wheezing? Swelling in lips / fingers? Hives?

Before transfusion did you have fever?

Check for haemolytic reaction – any back or flank pain?

P/E – no oozing at IV line

Then press on flank and back – no pain for haemolytic reaction.

Is it the first time?

Why did you receive blood?

If received blood before – was there any complications?

Any long term diseases?

Counseling

Mr. X what do you know about blood transfusion?

It is a life saving measure, and a lot of measures are taken to make sure it is safe.

However, like any other medication with blood transfusion there could be side effects, and these side effects could be serious.

The most common side effect is febrile reaction (3%), usually it is self limited and can happen again. Next time you receive blood we will give you tylanol.

Anaphylactic reaction. It is a severe allergic reaction, and it is very serious and we cannot predict it. However, we have good measures to deal with it, and your symptoms make it less likely that you have had an anaphylactic reaction. The yhird reaction reaction is more serious and called haemolytic reaction. Usually happens when patients receive blood belonging to another blood group. The fact that this blood is same as your blood group, and the symptoms are not consistent with haemolytic anemia make it less likely that this is not the case here. The blood is sent to the blood bank and once results are back we will get final confirmation, we will able to reassure you.

  Febrile Seizure



A child brought to the ER because of febrile seizure. Next 10m counsel him.

He is stable. During the next few minutes I’ll ask you few questions, and after that I’ll go with you to see him.

You should r/o meningitis. Educate, and what to do next time. Did you see him? (Started to shake. All over his body? Bite his tongue / roling up his etes / wet himself).

After the seizure does he have any neurologic deficits. How long did it last, or did you come on your by his own or medcial staff. Did he stop seizing on his own or after medical interv. Is it the 1st time?

Ask about fever? (if it started a week ago – did you seek medical assistance? Discharge? Did they give you any treatment? Did they give it to him or no?) Why! Some studies show you can treat OM without antibiotics. You should look for the reason not to give the antibiotics (negligence?). Is he having any vomiting? Skin rash? Coughing? Head to toe...

If you find nothing – ask when he got his last shot? (up to 72 hours he can have fever).

R/O meningitis, pneumonia.

Any family history of febrile seizures, epilepsy BINDE (especially immunization).

Counseling:

Your child has condition called febrile seizure (FS).

It is a condition that might happen from 6m to 60m. We don’t know exactly why – we believe it is a sudden change in the temp. This might lead to the seizure. This condition might happen again.

Any time your child has fever – seek medical admition. Give tylanol and sponge to decrease his temp.

Most of the children will outgrow this condition by the 6th year.

They don’t recommend Diazepam because it might make him drowsy.

If it stopped less than 5m or more than 5m including neurological symptoms seek ER immediately. Brochure.

“This is Dr. ... (immediately should introduce yourself). I am the Dr. In charge in the ER. I am calling that your child swallow medication. I know you are stressed, I need to take your phone number and address, and how far it is from the hospital.” Stay calm. Your son needs you, I am going to give you some instructions and you need to follow them. Is your son is alert or not? Is he conscious? Can he talk to you? Can he recognize you? If he doesn’t – do you know how to do CPR and start with that. He’s crying. What is colour? Pink. Hold him and try to calm and sooth him. If he his conscious – try to hold him and check his mouth. Is he breathing? We’ll send the ambulance for you. When did it happen? How long was he alone? Which medications did he take? Do you have the container? (don’t go to the next room to bring them). Do you know what condition your father have (was it vitamins, sleeping pills, or any other?) how much the amount? Don’t use any ippecak?

Is it happened before? What is the weight of the child? BINDE (was it full date, did he needed special attention after term, does he have any special conditions). Weight for two reasons – antidote and estimate neglect.

Post encounter Q: what are the first four steps you do when he arrives? (ABC, Monitor vitals, IV line, NG, Foley as needed, Blood works – CBC, Lytes, BUN, Cr, Osmolality, Coagul, LFTs, Tox screen – blood and urine).

List three risk factors for this child.

What is the antidote for betablocker (glucagon) and for CaChannel is (Calcium gluconate). CAS and Poisoning centre.

Second scenario – while he is seizing just put him on the side, and not start any CPR. Before I proceed I’d like to take your phone number and address. Is it the same time or happened before. If it is the second time – more than 15m he needs intervention. Is he seizing right now? Try to put him on the floor on the left side (the right bronchus is shorter than the lt.). Observe him. What is his colour? Is he still shaking? You send the ambulance. Can you tap on his shoulder? If he is not responding – can you do CPR? Can you feel his pulse? Is he alert? Can he talk to you? Can he move his legs? Was he shaking? Does your child have fever? Did you seek medical attention? What prevented you from giving the medication?



Post Concussion.

2 scenarios (Osgood schlatter and Post-concussion)

Decision will based whether the child can tolerate pain or not?

#1 About to see the father of 14yom with Osgood Schlatter.

Make sure that the child best interest are preserved. What was done to diagnose the child?

OCD PQRST compare to the other knee, is the first time or not, was any trauma. What is the child wish? (Don’t go for HEADDSSS since it is the father).

Counseling

What is your understanding of OS.



Let me explain to you what is the mechanism for OS. Avoid him from playing, especially jumping. But he can continue with ice presses and pain killers. The rule is that he can continue up to his limit of his pain.

54 year old female comes to clinic concerning about using HRT.

. When a patient has concern about any subject, address it very soon. Don't wait to the end.

Dr: As far as I understand you're here as you have concern about using HRT. Patient: yes Dr. I feel I am confused about using HRT. Always ask what do you mean by HRT. So the patient will tell you how much they known about HRT. Dr: I'm glad you're here so we can discuss about it and address your concerns and hopefully by the end of the session you can make a decision regarding using HRT. Or hopefully by doing this discussion you will have a better understanding of HRT.

Or you can say: I agree with you as there are a lot of confusion about HRT and the reason for this confusion is that in the past because it was used to be given routinely to all women who reach a certain age, however 10 years ago there was study called " women health initiative" in which the authors found that the numbers of the patients with serious side effects are very high. However those ladies used HRT for a long time.

Serious side effects are Cancer, Heart attacks and Strokes.

For that reason the routine use of HRT was stopped.

Nowadays we have a better understanding and have better guidelines. Not only that we do it on the individualized basis.

We use it only for short time, they don't exceed five years.

So using HRT within five years is safe.

So I would take some information from you and we will discuss about the risk factors and if you are a good candidates we can make a decision to prescribe it or not. Dr: What makes you interested in HRT?

Patient: because of hot flushes.

At this stage if the patient gives you the symptom, it is your chief complaint. But if patient doesn't give you any symptoms, you should start with her LMP If she starts with the symptom of hot flushes, ask the patient

1.When did hot flushes start,

2.Is it all the time,

3.On & off or continues,

4.How many attacks,

5.Day or night,

6.How do you feel that you have it.

7.Night episodes, you have any night sweating, does it wake you up. Asked patient if the hot flushes wake her up during the night and if she needs to change her gown of night’s sweats.

1.Affect your sleep and how does it affect your concentration. 2.Change in your mood, anybody has told you that your short tempered, and if you 3.feel tired.

4.Some women with the same symptoms may notice some change in their sexual life. a)So the doctor should ask with whom do you live?

b)Are you sexually active?

c)Any dryness or pain during the intercourse?

5.Any change in your urination?

6.Have you ever lost control?

7.Last period?

•Are you periods regular or not?

•If it's irregular, when did it start to become irregular?

•Are your periods heavy or not?

•Any clots?

•*Any bleeding or spotting between periods? This is a very important point. 8.Bone pain? Any fractures? Any family history of osteoporosis? If yes, tell the patient that you will discuss this in another meeting. Because that's another session to discuss about using steroids, smoking, alcohol, caffeine, warfarin and diet. If she takes calcium supplements.

MGOS for GYN cases: Menstural, Gynecologic diseases, Obstetrics, Sextually transmitted disease

Dr: any history of gynecological disease like polyps, cysts, any pelvic intervention/instrumentation, surgeries.

Dr: did you use to take any oral contraception? If yes, which one and did you have any side effects?

Also you should ask about her last smear.

Because she is 50+ you should ask about her mammogram.

At any age you ask about Pap smear, once you reach 50 to ask about mammogram and when the patient pass 65 you should add bone density.

You can ask about her obstetrics history, like have you ever been pregnant if yes how many times you have been pregnant?

Now use the transition...

Because this is the first time I met you, I would like to ask you about your past medical and social history. Is there any long-term disease, hospitalization before, any surgery, diabetes, or hypertension. Any history of allergy, and the medication she takes.

ABCD: Active liver disease, vaginal Bleeding, Cancer, DVT

For A you ask about any history of Active liver disease. Have you ever been yellowish? Any dark urine or pay stool?

For B you should ask about any vaginal Bleeding? ... You have already asked these question before

For C you should check about Cancer. I would like to ask about constitutional symptoms here to see if there is any endometrial cancer. Fever, chills, weight loss, appetite, lumps & bumps. A history of cancer in yourself or family (breast cancer, endometrial cancer,and colon cancer).

For D you should ask about any history of swelling in the legs (DVT), any history of heart attacks, pulmonary embolism or stroke.

Social history: smoking, taking alcohol, recreational drugs, how does she support financially herself, how does this affect her life and ask about osteoporosis. Usually in this set of scenario, you tell her on the basis of the history you are good candidates for HRT.

However as I told you it is an important information to tell you to make your decision. As we go through different stages of life usually for ladies, we go to the stage called menopause which is vary between person to person.

At this stage there is hormonal changes and ovaries start to produce less hormones specialty estrogen and progesterone and that changes affect the whole body. It can explain about dryness, decreasing or absence of periods. And that's why we try to replace those decreased hormones by HRT. They are the same hormones but we give it through external sources either tablets or skin patches.

As I told you before there is a balance it's your decision to make. And the balance is to use it up to five years. Using more than five years would increase the risk of stroke, heart attack or some cancers depending on what we call it estrogen dependent that includes breast and endometrial cancer. And some studies showed that it might increase the risk of Alzheimer's disease.

So the risk of use for less than five years is not significant and still acceptable. So if you want to use it the shorter the better.

To get rid off the hot flushes that are other measures like exercise or herbal supplements that you can try to improve the symptoms.

The HRTs are the same as OCP's but in this smaller doses and you can take one tablet a day. They have a few side effects like weight gain, bloating, nausea, abdominal distention and pain but they improve by time. This serious side effects are headaches, swelling of the legs or chest tightness which whenever happen you should go to emergency room. By using these HRT's your periods may stop or you may see spottings.

If the patient had hysterectomy before you only give estrogen without progesterone, otherwise you should give both.

Because you take it regular shootout regular ultrasound scans to check the thickness of the endometrium

CARDIO



1.45 yr old Chest Pain x 45 mins ER History x 5 mins (MI)

Onset:

1.When did it start?

2.What were you doing at that time?

3.How did you get here today?

4.If you came in by Ambulance, did the paramedics give you a tablet to be kept under your tongue?

Course:

Was it sudden or gradual?

Position:

Where exactly is it hurting you the most?

Quality:

Can you describe the pain? Is it crushing? Knifelike?.......

Radiation:

1. Does it move anywhere else in your body 2. Does it move to the back?

Severity:

On a scale of 1 to 10 where one is minimum & 10 is highest, where would you place this pain?

Associated symptoms:

CVS:

•N/V,Sweating?

•Heart racing?

•SOB/Orthopnoea/PND?

•Have you been under stress recently?

•Cough with blood tainted sputum?

GI

•Acid taste in mouth? • Heart burn? • Dysphagia • Pud?

MSK

•Have you had any trauma to the chest • Are there any blisters on chest?

RS

•Did you have any flu recently?

•Cough with Phlegm?

CONSTITUNIOL Sx

•Do you have night sweats

•Loss of appetite & Loss of wt?

Alleviating Fcts:

What makes you feel better?

1. Rest? 2. GTN?

3.Antacid?

4.Sitting forward? Aggravating Factors:

1.Exercise/exertion?

2.Movements?

3.Deep inspiration?

4.Lying down?

5.Eating?

RISK FCTS:

I need to know additional information that could be related to your pain right now, and need to ask some further questions...... 1.Do you have a high Blood pressure?

• When,& what did your doctor have to say about it? • Were you put on medicatn?

2.Were you diagnosed at any time with an elevated Blood Sugar or were told you had diabetes? • When,& what did your doctor have to say about it? • Were you put on medication?

3.Have you ever had your cholesterol checked?

If yes:

• When,& what did your doctor have to say about it? • Were you put on medication?

4.Do you smoke?

If Yes;

How many & Since how long?

5.Do you take alcohol

6.Have you used recreational drugs? Cocaine?

7..Do you find time for regular physical activity?

8.Do you eat a lot fast food?

9.In your family has anyone had a heart attack under the age of 50?

CAUSES/Consequences & Symptoms:

1.Did you ever have a stroke?

2.Did you have a weakness or numbness?

Past Medical History:

1.Do you take any medications?/OTC or herbal products?

2.Are you allergic to anything?

3.Were you hospitalized at any time?

4.Did you ever undergo any surgery?

5.Were you ever diagnosed with Cancer?

6.Do you have a bleeding disorder?

7.Did you have any head/facial trauma since last 3 mo?

I need some more information about your family HTN/DM/MI/Stroke

Social History:

1.With whom do you live?

2.How do you support yourself?

MANAGEMENT:

• Rapid, targeted history and physical examination, with particular attention to onset of symptoms, contraindications to use of thrombolytic agents Absolute contraindications:

1.Previous intracranial hemorrhage;

2.Known malignant intracranial neoplasm,

3.Known cerebral vascular lesion,

4.Ischemic stroke within 3 mo EXCEPT acute stroke within 3 h;

5.Suspected aortic dissection;

6.Active bleeding or bleeding diathesis (excluding menses);

7.Significant closed head or facial trauma within 3 mo.

Relative contraindications:

1.History of chronic severe, poorly controlled HTN,

2.Severe uncontrolled HTN (BP > 180/110 mm Hg)c;

3.Prior CVA greater than 3 mo or known intracerebral pathology not covered above;

4.Traumatic or prolonged (> 10 min) CPR or

5.Major surgery (< 3 wk);

6.Noncompressible venous punctures;

7.recent (2–4 wk) internal bleeding; pregnancy;

8.active peptic ulcer;

9.current use of anticoagulants.

and evidence of high-risk features (tachycardia, hypotension, congestive heart failure)

Management

1.ECG STAT, then every 8 hours for the first 24 hours, then daily for 3 days.

a. In addition, repeat the ECG with each recurrence of chest pain

2.Baseline troponin STAT, (creatine kinase if troponin is unavailable) and then every 8 hours until enzymatic confirmation of the diagnosis

3.CBC to rule out the presence of anemia,

4.Baseline electrolytes,

5.Creatinine,

6.Fasting lipid profile (within 24 hours of presentation)

7.Liver function tests

8.Portable chest x-ray (CXR) STAT

9.Echocardiography to assess LV function after stabilization and treatment.

Echocardiography is also used emergently when there is suspicion of acute mechanical complications post-MI Therapeutic Tips

•The goal for thrombolytic treatment is a door-to-needle time of 30 minutes or less.

•The goal for primary PCI is a door-to-dilatation time of 90 minutes or less.

•Careful attention to maximum pain relief is important.

•In patients with right ventricular infarcts:

oavoid nitrates and diuretics

ouse fluids and inotropes to treat hypotension

•Administer beta-blockers early to all patients without contraindications. Increase the dose every 12 hours (every 24 hours for once-daily beta-blockers), if tolerated (monitor blood pressure and heart rate), until the patient has reached adequate beta-blockade (HR ≤ 5565 BPM).

•Start ACE inhibitors early. The choice of agent can depend on practitioner preference, hospital formulary or financial constraints for the individual patient.

•In smokers, the need to quit smoking should be reinforced early (within 24 hours) and frequently.

•Stool softeners are often used in the immediate post-MI period to prevent straining with bowel movements.

•Anxiolytics are often used on an as-needed basis in the immediate post-MI period.

Early Management of STEMI

Hx

OCD

PQRST

(if it is suspected to be ACS - stop at R and start primary survey) Primary Survey (If patient talks – Airway preserved, take Oxygen saturation and start Oxygen Stat – 4L/m through nasal prongs)

Vitals

Auscultation: normal air entry and normal S1, S2

IV lines (normal NaCl 50ml/hr to keep line open, from the other side take blood for: Troponin, CK-MB, Cr, BUN, Lytes, CBC, INR, PTT, LFT, Toxic., Alcohol, Lipids; and finger prick for Glucose)

ECG 12 leads and continue monitoring

Ask about Allergy and Viagra (if negative) Give ASA chewable (325mg)

Non-ST elevation: give Nitro x3 (S.L) if there is no benefit – give Morphine.

Continue

PQRST

AA&A

How do you feel now?

Ask Hx on CVS and GI (especially peptic ulcer)

CSx

RS

DVT

ST Elevation: do not go for DDx, Vitals (again)

RF

Nitro (2nd dose) Examination:

JVP

Listen to heart

Base of lung

Compare BP in both Upper extremities to r/o coarctation of Ao

CXR

Once there is no Aortic Dissection  Thrombolytics (should be clear to r/o: Peptic ulcer, recent surgery, pericarditis, aortic dissection, brain tumor, and stroke) Based on ECG – counselling

Counseling

Based on your ECG it is most likely you are having an heart attack. If stable – BP and HR are stable, but it is a serious condition, however it is treatable. Heart attack means that greater than one blood vessel supporting your heart is blocked by a clot that has to be reimoved. The medications are called clot busters. Based on ECG and no sign of pericarditis or signs of aortic dissection you are a good candidate for treatment. It is an effective medication, needs consent. 1% chance of stroke and we can start heparin.

PALPITATIONS



A 37 M/6wks [H&PE] B.30F/4wks[H&C]

Dd:

VITAMINS C

VASCULAR: SVT,Rapid atrial fibrillation,& V Tach

METABOLIC:Fever,Anemia,Hyperthyroidism,Acromegaly

NEOPLASTIC: Pheochromocytoma

SUBSTANCE ABUSE & PSYCHIATRIC DRUG INGESTION (sympathomimetic) Drug Withdrawl,Anxiety

CONGENITAL:WPW Syndrome

>48 hrs not panic attack

OCD:

O: When did it start? How did it Start?

Sudden/Gradual

What were you doing at that time?

C:

Does it come in bouts or Continous?

How often does it occur?

What was the duration of the attack?

D:

How long since you’ve had these palpitations?

How long does each episode last? / ? > 48 hrs?

PQRSTUV

Q:

Ask Pt to tap with his fingers the heart beat.

Does it Miss abeat/Racing/Slowing of heart beat?

S:

On a scale of 1 – 10 How has it affected the quality of your life?

T:

Does it occur even at night?Is it the first time or has it happened before?

Emphatize: I know it can be a fairly scary feeling

AA&A

A: What makes it worse:Coffee/Recreational drugs/Stress/Smoke(extrasystoles)Choclates/Alcohol A: Anything makes it better?

How was your health prior to the palpitations?

ASOC Sx:

CVS: Chest Pain/SOB/Orthopnea/PND/Dizziness/Sweating/N/VSwelling of feet/Cough

CNS: Weakness/Vision loss/Difficulty in finding words/Numbness or loss of sensation THYROID: Do you feel hot/cold

Do you have wt loss inspite of increased appetite?/Tremors?Shakiness?Sweaty palms & moist skin? PHEOCHROMOCYTOMA: Repeated headaches,with increased sweating

CARCINOID:Flushing/Diarrhoea

CNS:In last few weeks did you notice any difficulty in Walking,numbness,finding words? (Look for Sx/o Embolism) CONSTITUTIONAL Sx: Fever/Chills/Loss of appetite/Lumps & Bumps

RISK FCTS: Smoking/Alcohol (Holiday Heart)/Recreational drugs

PMH:

•Are you on any medications?

•Have you seen a psychiatrist?

•Any OTC/Herbal products/Cold meds/Asthma meds • Are you allergic to anything?

If Allergic to Penicillin:

1.When did you find out?

2.Where did you take it?

3.Why did you take it?

Do you have any Heart disease/HTN/DM/Stroke/Ca/MI H/O Rheumatic fever as a child?

Did you get repeated sore throat infections as a child?

Did you receive Penicillin injections regularly as a child?

HTN

History:

OCD

o O: *When did you notice your BP was high?

*When was your last (N) BP o Duration of hypertension,

*Usual level of blood pressure and

*Any sudden change in severity of hypertension o History of antihypertensive drug use,

*Reason for changing therapy,

*effectiveness,

*side effects and intolerance (IMPOTENCE) o Drugs that may cause hypertension drugs that may interact with antihypertensive drugs (those that induce or inhibit metabolism) o Adherence with lifestyle recommendations and drug therapy

HOME MONITORING

END ORGAN DAMAGE:

1.Angina/Mi: Chest pain/SOB

2.TIA/Stroke:LOC/Vision changes/weakness/Numbness

3.Peripheral Vascular disease/Leg pain/ED/

4.Kidney disease

SX of SECONDARY HTN, ,

1.Pheochromocytoma (hyperadrenergic symptoms)Do you have episodes of palpitations/HA/Sweating?

2.Hyper- and hypothyroidism: Feel Hot/Cold/Tremors

3.Cushing’s syndrome: Bruising of skin/Wt gain

4.Renal/urinary symptoms or a past history of renal disease

RISK FCTS:

1.Cigarette and alcohol use,

2.Usual physical activity

3.Usual diet and sodium intake,

4.Current weight and recent weight change, waist circumference,

5.Diabetes

6.Dyslipidemia

PAST MED HISTORY

1.Medications Pt is on/OTC/Herbal

2.Allergies

3.Hospitalizations/Surgery

FAMILY HISTORY

•Hypertension,

•Cardiovascular risk factors

•Premature cardiovascular disease

SOCIAL HISTORY

Nonpharmacologic Choices

Effect of Lifestyle Changes on Blood Pressure in Adults with Hypertension

Intervention Change in Blood Pressure (systolic/diastolic) mm Hg

1.Reduction in sodium ↓ by 1800 mg (78 −5.8/−2.5 intake mmol) per day

2.Weight loss 4.5 kg −7.2/−5.9

3.Reduction in alcohol ↓ by 2.7 drinks/day −4.6/−2.3 intake

4.Exercise 3 times/week −10.3/−7.5

5.Dietary DASH dieta −11.4/−5.5 recommendations

•Weight loss of 4 kg or more if overweight (target body mass index: 18.5 to 24.9 kg/m2; waist circumference <102 cm in men and <88 cm in women).

•Healthy diet—high in fresh fruits, vegetables, soluble fibre and low-fat dairy products, low in saturated fats and sodium, e.g., DASH diet available at Sodium intake of 1500 mg (65 mmol) per day for those aged 19–50 years, 1300 mg (56 mmol) per day for those aged 51–70 years and 1200 mg (52 mmol) per day in those 71 years and older.

•Regular, moderate intensity cardiorespiratory physical activity for 30–60 minutes on most days.

•Low risk alcohol consumption (0 to 2 drinks/day, < 9 drinks/week for women and < 14 drinks/week for men).

•Smoke-free environment.

SYNCOPE



Volume depletion and drugs Volume depletion

•Diarrhea

•Diminished oral intake

•Polyuria

Drugs

ACE inhibitors

oAlcohol

oAlpha- and beta-adrenergic blockers o Antiparkinsonian drugs o Diuretics o Nitrates

oPhosphodiesterase type 5 inhibitors (sildenafil, tadalafil, vardenafil)

o Vasodilators Orthostatic intolerance disorders

•Reflex syncope syndromes o Carotid sinus hypersensitivity o Vasovagal syncope syndromes

•Autonomic neuropathies o Pure autonomic failure syndromes o Multiple system atrophy syndromes

•Arrhythmias

1.Bradycardias oComplete (third degree) and bifasicular heart block o Sinus node disease

2.Tachycardias oSupraventricular arrhythmias (uncommon) o Torsades de pointes polymorphic ventricular tachycardia o Ventricular tachycardia

Obstruction

•Aortic stenosis

•Pulmonary emboli

•Many other rare causes

Investigations

In patients with transient loss of consciousness perform a complete cardiovascular and neurologic history and physical examination. Rule out seizures, then screen for life-threatening causes such as obstruction, ventricular tachycardia and asystole or heart block

•Tailor laboratory investigations to the individual patient:

oECG (most patients)

oolder patients ( >55 years) should have ambulatory ECG monitoring unless the history is strongly persuasive for vasovagal syncope.

oechocardiogram or other noninvasive measure of left ventricular function if structural heart disease is suspected

ocoronary angiography as indicated o refer patients with structural heart disease for electrophysiologic assessment o unless contraindicated, carotid sinus massage should be performed in patients >50 years old to screen for carotid sinus hypersensitivity (do not perform in patients with carotid bruits)

otilt table testing might be useful in diagnosing vasovagal syncope in patients with atypical symptoms

•After potentially fatal causes are eliminated and reversible causes are removed, most patients will have one of several syndromes of orthostatic intolerance:3 o reflex syncope syndromes

•vasovagal syncope

•carotid sinus hypersensitivity in the elderly o pure autonomic failure syndromes o multiple system atrophy syndromes

•The orthostatic intolerance syndromes can be distinguished based on history and a simple stand test in the office. To perform the stand test, first measure blood pressure and heart rate after the patient has been supine for 5 minutes, then after 2 and 4 minutes of standing. These responses are seen: Normal and vasovagal syncope: modest rises in heart rate (about 10 BPM) and blood pressure (about 10 mm Hg). Autonomic failure: progressive fall in blood pressure of ≥20 mm Hg systolic or ≥10 mm Hg diastolic with development of presyncope; often no increase in heart rate.



Treatment is directed at the cause of syncope. Treat any reversible causes. Refer patients with syncope secondary to bradycardia (asystole or complete heart block) for a permanent pacemaker. Refer patients with suspected or diagnosed ventricular tachycardia, and all patients with structural heart disease to a cardiologist, preferably an electrophysiologist. The following addresses treatment of syndromes of orthostatic intolerance. Nonpharmacologic Choices •Reassure the patient that this syndrome is not life threatening and that it is a physical problem, not a psychiatric disorder. Encourage increased dietary salt intake of about 3–5 g daily, in the absence of contraindications such as hypertension or heart failure.5 , 8 •Teach the patient to use physical counterpressure manoeuvres at the onset of presyncope.9 , 10 These include squatting, crossing the legs with isometric contraction if standing, and vigorous hand clenching with upper girdle isometric contraction. All should be tried. The evidence is based on a good physiologic study10 and an open label randomized clinical trial.9 •Pacemaker therapy is no longer indicated, based on the results of an adequately powered randomized placebo-controlled trial.11 The occasional patient with asystole documented during vasovagal syncope might benefit, and these uncommon patients should be assessed at a tertiary referral cl

65/F Calf Pain x 10 weeks





How many blocks you could go? How many now?

How fast the pain disappears after resting?

Is the pain alleviated by bending forward or extending backward? Is it awakening you at night? Ddx:

1.Spinal Stenosis (Pain disappears about 15min after resting, alleviate by leaning forward)

2.Disc herniation (Pain disappears about 15 min after resting, alleviated by extending)

3.Intermittent Claudication (After resting – pain disappears by few minutes)

4.PE

5.Cellulitis

6.Ruptured Baker’s cyst CC:

Unilateral Vs (B) O:

Can you tell me when it all started?

Sudden Vs Gradual

What were you doing at that time?

What made you come in today?

C:

Is it Increasing,decreasing or same? Has the intensity increased?

*Does it awaken you up at night?

D:

How often does each episode occur?

How long does it last?

PQRSTUV:

R:Does it move anywhere else in the body? Buttock/Toes/Feet/Thigh T:When does it come on?

When you walk?

How many blocks can you walk when it comes? ------ >Now & at the beginning? Reproducible pain

U

V:

•Has it happened before?

•If Yes When?

•How Often?

AAA:

AGGRAVATING:

Stand/Sit?

When you walk uphill or downhill?

When you raise your leg?

ASSOC. SX:

CONSTITIONAL Sx: Fever/ /night sweats/Loss of appetite & los of Wt/Lumps & bumps. Local Sx:

1.Swelling/Raised temp

2.Back Pain or Trauma to back or knee/Morning stiffness

3.Numbness/Tingling/Weakness/Burning sensation 4. Change in nails/Hair loss/Skin is it shiny/any Ulcers?

5. Are your feet cold? CARDIAC:

Chest pain/Palpitations/SOB *How is your sex life? Desire & Erection?........ How has this affected your life?

RS:

Cough

RISK FCTS:

I need to ask you some more qns that will help me arrive at a diagnosis of your pain: 1.Do you Smoke? 2.Drink Alcohol? 3.Have you recently travelled a long distance in an airplane? 4.Were you at any time Diagnosed as HTN,Is it Rxed & Under control? When was the last time you saw your Dr.? 5.Were you at any time Diagnosedwith high blood sugar?Is it Rxed & Under control? When was the last time you saw your Dr.? 6.Have you checked your cholesterol? ....... 7.Did you have recent surgery?

PMH:

I need some information about your health in general: •Are you on any meds?/OTC/Herbal products? •Allergies? •Were you ever hospitalized?

FHx

SOCIAL:

•Who lives with you? •How do you support yourself financially?

ANKLE SWELLING 30 M x 10 days



A. Gout B. CHF Dd: A. UNILATERAL 1.Trauma 2.Arthritis: Gout/SepticA 3.Cellulitis 4.Varicosities B. BILATERAL 1.CHF 2.Nephrotic 3.Liver failure 4.Myxoedema 5.Protein losing enteropathy First Qn: Unilateral or Bilateral OCD: O; Sudden/Gradual Off & On/Continous Everyday/Certain time of day Related to activity/Standing PQRSTUV: P:Above kne/Below knee Posture

AA&A What makes it worse: Activity/Alcohol & diet(Gout)/Standing Alleviating fcts:Rest with elevation of feet....

ASSOC Sx:

LOCAL Sx:

In addition to the swelling did you notice any: Pain/Stiffness/Fullness/Redness Did you notice swelling anywhere else? Face/Eyes particularly did you feel your eyes were puffy in the morning/Increasing waist size/Rings are tighter? CONSTITUTIONAL Sx: Fever/Wt loss/Night sweats/lumps & bumps CARDIAC Sx: Chest Pain/SOB/Heart racing GI/LIVER Disease:Yellow discoloration of skin/Pale stools/Dark urine KIDNEY DISEASE:Change in the amount of: Urine/Color/Consistency (Frothy/Cloudy)/Odour RISK FCTS: I need to ask you some more details to get more insight into your condt: Do you Smoke,Take Alcohol or Recreational drugs? What is your diet like? Do you eat a lot of red meats? (GOUT)

PMH:

Any meds you’re currently taking?(*Aspirin & Thiazides for gout)/OTC/Herbal products? Have you ever been diagnosed with HTN/DM/MI/Stroke/Ca? Were you ever hospitalized or undergone any surgical procedure? FH:

Does anyone in the family have a similar condt?

DM/HTN/MI/Stroke?

SOCIAL H: Who lives with you

How do you support yourself financially?



24 female, acute asthma in ER, 3 dasys ago,asthmatic for the last 3yr comes to you at clinic for F up As I understand you were in ER 3 days ago with an attack of Ac asthma. HOW DO YOU FEEL RIGHT NOW?

Event – Before Event After OCD Can you tell me what happened at that time? SX: 1.Sudden/Gradual 2.Was there Wheezing? 3.Chest tightness? 4.Were you able to talk? 5.How many times did you use the puffer? 6.How did you get to the ER? 7.What did they do in the ER? 8.Were you intubated? 9.What medicines did they give you?

Asthma history

Let us talk about Asthma history: 1.When were you diagnosed? 2.How were you diagnosed? 3.Are you on regular f/Up? 4.When was the last time you were seen at F/up? 5.Have you visited the ER before? 6.Did you notice any increase in nos of attacks? 7.Do you have attacks at rest? Attacks at Night? 8.Did you dr adjust your meds at that time? 9.Which meds do you use? 10.How often do you have to use your medicines? 11.Are you using the meds more frequently? 12.Triggers 13.Do you suffer from heart burn or condt called GERD? 14.Do you user a peak flow meter?

I need to ask more qns which will help me to clarify as to why you had an attack recently? 1.Have you had recently any flu/infection? (any chest infection upto 10 wks post infection hyperreactive airways) 2.Can you show me how you take medication? (Shake it, put it in your mouth, take deep breath when puffing). 3.Do you make sure your medication are not expired and stored expired? 4.Did you started any new medication that might interfere (beta blocker / aspirin)with your asthma? 5.Outdoor – cold weather, pollens, exercise, construction, dust 6.Indoor – a.Do you smoke or anyone around you, b.Pets or people around, c.New curtain, indoor plants, carpets, curtains, pillows. d.Basement – mould, renovations, paintings; 7.Relation to any type of food; 8.Strong odour

Important to classify – mild / moderate / severe

I want to ask you…

What do you do for living? PAST H: Any HTN/DM Hospitalizations/Surgery FAMILY H: Same Condt DM/HTN/Stroke SOCIAL H Do you take alcohol/recreational drugs? How do you support yourself financially?

Asthma Treatment

Very mild, intermittent asthma may be treated with fast-acting beta2-agonists taken as needed. Inhaled corticosteroids (ICS) should be introduced early as the initial maintenance treatment for asthma, even in individuals who report asthma symptoms less than 3 times a week. Leukotriene receptor antagonists (LTRAs) are second-line monotherapy for mild asthma. If asthma is not adequately controlled by low doses of ICS, additional therapy should be considered. A long-acting beta2-agonist (LABA) should be considered first as add-on therapy only in combination with an ICS. Increasing to a moderate dose of ICS or addition of an LTRA are third-line options. Theophylline may be considered as a fourth-line agent in adults. Severely uncontrolled asthma may require additional treatment with prednisone. Omalizumab may be considered in individuals 12 years of age and over with poorly controlled atopic asthma despite high doses of ICS and appropriate add-on therapy, with or without prednisone. Asthma symptom control and lung function tests, inhaler technique, adherence to asthma treatment, exposure to asthma triggers in the environment and the presence of comorbidities should be reassessed at each visit and before altering the maintenance therapy. After achieving proper asthma control for at least a few weeks to months, the medication should be reduced to the minimum necessary to maintain adequate asthma control. Short-acting Inhaled Beta2-agonists (SABAs)

Salbutamol and terbutaline are selective beta2-agonists that are agents of first choice for treatment of acute exacerbations and for prevention of exercise-induced asthma. They are best used as required rather than on a fixed schedule. Although potent bronchodilators, they have little effect on the late (inflammatory) phase of an exacerbation. If patients use a short-acting beta2-agonist more than 4 times per week (including any doses used to prevent or treat exercise-induced symptoms), initiate therapy with an anti-inflammatory agent.4 Isoproterenol and epinephrine are not recommended for the treatment of asthma because of lack of beta2-selectivity and potential for excessive cardiac stimulation, especially at high doses.

Long-acting Inhaled Beta2-agonists (LABAs)

Salmeterol and formoterol are long-acting beta2-agonists for regular twice daily treatment of asthma. Salmeterol has a slow onset of action and should not be used for immediate relief of bronchospasm. Formoterol is rapid acting and can be utilized for rescue therapy. These drugs help to prevent exerciseinduced bronchospasm.5 Both should be used only in patients already taking inhaled corticosteroids and may be particularly useful for the prevention of nocturnal symptoms. Adding long-acting beta2-agonists to 6 inhaled corticosteroids may permit decreasing the latter’s dose.

This information was originally published in Canadian Respiratory Journal 2010;17(1):15-24.

ACUTE COUGH

Cough for the last 5d

Local Cause Community acquired Pn HIV In young Pt can ask directly H/o HIV Status In HIV(Pneumocytis Jevorici there is (B) chest pain & night sweats OCD:UV

O How did it start: Sudden/Gradual? C: Is it first time or have you had it before? Is it increasing/Decreasing or same intensity now as it was in the beginning? Does it wake you up from sleep? EMPATHY if awakens him up NATURE: Dry/Wet If Wet: COCA Color Odour Consistency Amount Blood CHEST PAIN: PQRST Constitutional symptoms RESPIRATORY Sx: 1.Shortness of breath, 2.Tightness, 3.Wheezing, 4.Ear pain 5.Sore throath CARDIAC Sx: SOB/ Heart racing Chest ain S/o Meningitis:

RISK FCTS: 1.Recent contact with sick people, 2.Vaccination for flu 3.TRAVEL H 4.Smoking 5.Alcohol 6.Drug abuse Past Med H Any meds/OTC/Allergies Asthma/DM/Similar condt Hospitalizations/Surgery FAMILY H SOCIAL H: Habits IF HIV + PT:

DO you know your HIV diagnoses? *When? *Where? *Regular follow up? *Medication? Taking/or not? *Last CD4? *H/O Thrush? PAST MED H Allergy COUNSELLING: PE/ CXR & Bl work Admit today

Cough for the last 6w



Increasing, not improving DID you seek medical attention?, what make you come today? Is it the first time? OCD O How did it start: Sudden/Gradual? C: Is it first time or have you had it before? Is it increasing/Decreasing or same intensity now as it was in the beginning? Does it wake you up from sleep? EMPATHY if awakens him up What made you come in today/ NATURE:

Dry/Wet

If wet first & then dry 2 elements: 1.Previous episode Sx: When productive:Fever/chills/Night sweats/ muscle pain & joint ache/COCA 2.Dry cough Sx: From that time till now,do you have fever?chills,muscle pains? Sx of infection? PATTERN OF COUGH: 1.Whole day? 2.How often? 3.How may attacks? 4.How long each attack? 5.Any particular time of the day?or 6.Do you wake up in morning with cough?(NIGHT COUGH: GERD/Asthma/CHF) (MORNING COUGH: PND/GERD) 7.When you cough do you cough to the extent that you’ve: a.SOB b.Difficulty talking c.Wheezing d.Chest pain e.Sweating f.(in children----> vomit) RISK FCTS: I need to ask some qns now that could lead me to the cause: •H/o repeated sinusitis •Facial pain •Ned to clear throath •Runny nose •GERD: H Burn Acid taste in mlouth Relation to lying down/bending forward How many pillows do you need at night Do you get up in night gasping for breath/

•ASTHMA; h/o Asthma

Relation between cough & outdoors or indoors • SMOKING H: Self: How many/ How long Those around you •Pets What do you do for a living/ Any exposure to dust? Any perfumes? D/D Other causes of Ch Cough 1.Medications: a. HTN; ACE/Aspirin/NSAIDS 2.Swelling in legs 3.Rcent travel 4.Contact with Tb 5.H/o Lung Ca

CHEST PAIN: PQRST Constitutional symptoms RESPIRATORY Sx: 1.Shortness of breath, 2.Tightness, 3.Wheezing, 4.Ear pain 5.Sore throath CARDIAC Sx: SOB/ Heart racing Chest ain S/o Meningitis:

67Male with Hemoptysis



Same check list as H Uria look for pulmonary Sx

Intro: As I understand you’re here because you’ve cough x 1 week? Any chance you may be vomiting? OCD Duration: Night? COCA + Bl Sx of Hypovolemeia: Dizziness/Faint/Tiredness/Loc A & A ASx: RS CSx: Hoarse voice Risk Fcts; Smoking Contact with TB/Screened for TB Travel outside Canada Exposed to asbestos H/O Dvt,Calf pain,redness,swelling of calves H/O Hd: PND/Orthopnea H/o Blood thinners Bleeding from any parts of body CNS: PMH

SOB/67 F x 6wks [5min/H]

HF

Dd: VITAMINS

VASCULAR:CHF,ACS,PE Precipatants of CHF:

•Meds: * Stopped * NSAIDS •Increased Na intake INFECTIONS:Pneumonia TRAUMATIC:Pneumothorax METABOLIC:DKA IDIPATHIC/IATROGENIC:COPD/Asthma/Massive atelactasis NEOPLASTIC: Large pleural effusion FIRST evaluate:ABC,ask pt if she is comfortable....... OCD: O:Sudden/Gradual What were you doing when you had this SOB? ---Exertion/Lying down? C: *SOB first always ask if difficulty in breathing is for: Breathing IN or Breathing OUT Does it occur all the time or only now Is it related to activity or does it occur even at rest If brought on by walking? How many blocks can you walk now as compared in the beginning? If at Rest? Do you sleep well? How many pillows do you need? Do you wake up at night gasping for breath? D:

How long?

If assoc Leg swelling,---- How long since leg swelling? PQRSTUV: S: On a scale of 1 – 10? T: Has it ever happened to you before?If so,how often? When was the last time you had SOB? How did you cope? U: How has it affected your life & how do you manage? Do you have someone to help you? [EMPATHY] AAA AGGRAVATING FctS: Exercise POsition Exposure to cold air? Infection? Allergies? ALLEVIATING FctS;

ASSOCIATED SYMPTOMS:

CONSTITUTIONAL Sx; Fever/Chills/Wt loss/Lumps/Bumps RS: Cough/Sputum GI: Dec appetite (Liver & GI congestion) Increase in waist size (Ascitis) CVS: Wt gain/weakness/Fatigue (Decreased cardiac Output) Chest pain/Sweating/N/V/Heart racing/dizziness/Nocturia Leg Pain/Leg Swelling/Wt gain THYROID: Do you feel cold/Hot /tremors RISK FCTS: I need some more details about you to get a better understanding abt your condt & hence need to ask you a few more qns Do you smoke? Take alcohol? *Take your meds regularly? *Any change in your diet recently? --- Are you eating more canned foods or have you been taking salted nuts *Do you measure the Na in your diet? Did you notice you’re pale? PMH: Were you ever diagnosed with HTN? What meds do you take? Have you taken your meds regularly? Were you ever diagnosed with a heart condition? Which HD?When were you diagnosed? How were you diagnosed? Do you have regular follow ups? When was your last F up? During your last visit, did your Dr add or remove any medications? How were you doing? Were your symptoms controlled at that time? Particularly ask about Dixogin: How much/How long/Dose/did you have your levels checked/any chance that you might’ve missed a dose? Particularly ask about Water pills: NSAIDS DM/MI/Cholesterol/Stroke/Ca/Hospitalization/Surgery FH: FH of premature deaths

SHORTNESS OF BREATH – POST SURGICAL



Surgery 3 days ago: SOB x 45 mins D/D: 1.Volume status (low & High) 2.Atelectasis 3.Pneumonia 4.Heart Failure 5.Embolism 6.Fat embolism INTRO: As I understand, you’d surgery 3 days ago & I’ve to do a PE on you VITLAS please I would like to R/O orthostatic hypotension Respiratory Rate G/E: Orientation: • Time •Place •Person Head: Sclera & Pallor Mouth: S/o dehydration No Central cyanosis No nasal flaring or pursed lips No S/o Respiratory distress HANDS: Capillary refill

Clubbing

Cyanosis Skin: Hot/Cold Pulse: Rate & Volume LEGS: Dorsalis Pedis Temperature Pedal oedema Feel for DVT Measure diameter of (B) calves Homann’s sign NECK: JVP Trachea S/o respiratory distress & use of accessory muscles of respiration L Nodes for pneumonia CHEST: Inspection: Symmetrical No IC retraction No accessory muscles No obvious pulsations No PMI seen FEEL Apex beat

LUMP In Breast/Neck



40/F h/o lump in Breast x 8 wks INTRO: As I understand you’ve a lump in your breast since 8 weeks, can you tell me more about it since it all started?

OCD:

O: HOW did you notice it? Routine examination or Accidentally? C: From that time to now, is it increasing, decreasing or remaining the same? V: Is it the first time, or have you noticed it before? Any relation to periods? Did you notice it on the upper or lower half of breast or inner or outer side? Do you feel it reaching into the arm? SIZE: How do you estimate the size? Chickpea/Olive/egg/Orange? Hard/soft/rubbery? Pain+/- Skin: slides or fixed? Changes in skin above: redness/ulcers Lumps in other breast Nipples: Dischareg/changes/ulcer? CSX: TRAUMA to breast? METASTASIS: Ha/Nx/Vx/Back pain/Cough/numbness in hand/Tired/pruritus? I’m going to ask you qns that may explain this:

RISK FCTS:

1.H/o Ca in breast or other breast? 2.If any biopsy was performed on the breast? 3.FH of Ca breast 4.LMP 5.Have you ever been pregnant & at what age your first pregnancy? 6.Have you breast fed? 7.Any OCs & for how long? 8.Do you smoke/alcohol? 9.H/o Ovarian or uterine Ca 10. Fatty Diet?

LUMP IN NECK:16/F X 2 WKS



D/d: Reactive Adenitis --------> Recent Flu Tooth problems ---------> Lymphoma ----------> Hard IM HIV INTRO: WHERE? HOW : OCD: SIZE: FEEL: Pain +/- SKIN changes Any other lumps? CSx: Sore throat / dyspahgia? Hx/Nx/Vx? Skin rash? Ear discharge? Sinusitis/cough/Pglem? H/o Ca or malignancies? HEADSS Abd pain Vaginal discharge Urine changes PE: Vitals: Look & asses the lump Look for any other lumps: Cervical LN/Supraclavicular/axillary Mouth PA: Liver & spleen Groin LN Popliteal fossa Pelvic & Vaginal exam Rectal exam Back to Content

TIREDNESS 45M with tiredness x 6 weeks As I understand you’re having Tiredness since 6 weeks, can you tell me more about it since it all started? Pt says he is concerned. STOP & ask about his concern. He says he is Air traffic controller & his vision has been blurry Pt says, he is also never been so tired before. Clarify: What do you mean about Tiredness? •Sometimes I do not feel refreshed after sleep. •Do you feel lack of energy? Like you cannot move your arm above your head. The Statement: NOT REFRESHED ANYMORE points to an organic cause OCD + Relation to sleep +/- Mood If Mood Sx + ------ MOAPS If Organic cause ---- Red Flags OCD At onset you can ask if there were any flu-like Sx initially (Thyroiditis) •Do you sleep more •When do you go to bed? •Do you wake up in the middle of the night •Which time of day/Night do you feel most? •Ask Nature of work; If shift •With whom do you sleep? •Does your partner C/o you snoring or jerky movts of limbs? (Restless Leg) •Do you feel better in morning or evening(if tired in morning-->Depression If evening-------->Organic cause)

1.Ask Constitutional Sx first: Fever/Wt loss/Night sweats/Chills/Lumps & Bumps Then quick review of Sx: 2.Cardiac: Chest Pain/SOB/Palpitations 3.Pulmonary: Cough/Wheezing/Phglem 4.GI: N/V Abnormal bowel movts/Diarrhoea/Malena/ 5.Liver: Dark urine/Yellow sclera/Abd pain/Loss of aooetite/Pale stool/Itchy skin 6.GU: Change in color of urine/Amt of urine/Cloudy/Frothy urine/Dysuria/Facial swelling 7.Anemia: Bleeding gums/Easy bruising/Malena/Haematuria/Female: Meorrhagia & LMP 8.Autoimmune Disease: Joint Pains/Skin rashes/Oral Ulcers 9.Endocrine: Thyroid: Feel hot/Cold Skin Moist/Dry/Tremors/Wt loss 10.DM: Risk fcts: FH & Lifestyle Once Pt has DM in history, GO over ALL Sx & Sy: A. Fluctuating 6 Sx 3 High: 1.Increased eating 2.Inc Drinking 3. Inc urination 3 : 4.Tired 5.Wt loss 6.Blurry vision B. Complications:  Micro: 1.Retinopathy: Black spots 2.Neuropathy: Tingling/ numbness 3.Nephropathy: Inc Urine 4.Impotence: Sometimes people with this condition have marital problems; Do you have changes in desire or difficulty in having or maintaining an erection? 5.Autonomic Dysfn: •Orthostatic hypotension •Gastroparesis •Diarrhea •Voiding difficulties •HTN  Macro: 1.Coronary Artery Disease: Chest Pain/SOB/ 2.CVA: Weakness/numbness/difficulty finding words/Sudden visual loss 3.Peripheral Vascular disease: Pain in calves/Cramps/Cold feet Skin infections Candidial infections in women

RISK FCTS: 1.Diet 2.Exercise 3.FH 4.Smoking 5.Alcohol 6.Recreational drugs

PAST MEDICAL HISTORY: Any medications/OTC/Herbal/LMP Surgery/Hospitalization

FAMILY HISTORY: DM/HTN/Stroke/MI

SOCIAL H: Habits With whom do you live? How do you support yourself financially?

Here Counselling should be short Focus on Blurry vision in relation to DM & why he needs to correct it. As I told you DM is a lifelong disease & it is imp to have the BSL controlled. Without proper BSL control, the increasing Blood sugar damages the blood vessels in our body, & leads to heart attacks, Strokes, Kidney failure. Also visual loss & feet ulcers I will have to refer you to a diabetic clinic However I will do basic blood inv & ECG first

35 M in hospital setting had a DKA 3 days ago x 5 mins H He is diabetic since 25 years



Here we’ve to look for Rf & see that are not repeated

As I understand you were seen in the hospital by my colleagues & Rxed for a condt called DKA 3 days ago. Can you tell me what exactly happened to you at the time? Xxxxx 1.Was there abdominal pain 2.Vomiting? 3.Were you drowsy? 4.Was there loss of consciousness? 5.How did you get to the ER?

6.When were you Diagnosed ad Diabetes? 7.How were you Dsed? 8.What type of Dm? 9.Which medications do you take/ 10.Insulin? 10.1How much? 10.2When was the last time your insulin was adjusted? 10.2 What was the wt at that time/ 11.Any loss or gain of wt? 12.How often do you monitor your bl Glucose? 13.When was the last HbA1c 14.Did you have DKA before? 15.When was the last time you had it/Are you under regular F/U? 16.How were you doing for the last few mths? Ask about Sx control: Blurry vision Inc thirst Inc Peeing Wt loss

Any idea why Sx are not controlled? DIET What about diet? How often do you party? Do you modify your diet when you party? Do you adjust insulin when you party/ If you take alcohol do you count it as a part of your calories EXERCISE: Any RECENT INFECTION/FEVER?

LONG TERM COMPLICATIONS: Have you ever had an eye check/ When was the last time you saw an ophthalmologist? Any retinal complications/ Any H/o heart attack? How are your feet/ Any feet ulcers? How is your urine,is it frothy/Cloudy/ Do you have tingling/numbness Thank you for the information,we will have to do further assessment 38M requesting a note to say he is well & fit to work Cannot see at work, works as an accountant.

ABDOMINAL PAIN/ACUTE ABDOMEN



1. Acute abdomen x 24 hrs 45/M Er x 5min H 2. Dysphagia x 6 wks 55M 3. Inc LFT: a.35 M ALT>>AST b.55M AST > ALT 4. Diarrhoea: a.Ch Diarrhoea x 6 wks H & PE b.Ch Diarrhoea x 6 wks H & C c.Ac Diarrhoea x 3 days H x 5mins

AC ABD: Acute abdomen x 24 hrs 45/M Er x 5min H As I understand you’ve abdominal pain since 24 hrs. Are you comfortable sitting down? Please bear with me for 5 mins till I find the cause of this pain & then I can give you something for relief OCD: O: Gradual/Sudden C: From the onset till now,is it: Inc/Dec Off & On/Ct-ous How was it at first? When change in course,QUALITY & SEVERITY is significant P Q: Ask nature from beginning R S T: Any relation with time? Before eating/After eating U: How was your sleep? V: Alleviating: Eating/Antacids/Defecation/Meds? Aggravating Fcts: Food/Posn/Alcohol/Meds? Assoc Sx: •Nausea •Vomiting: If +ve: *Color *Odour *Consistency *Amount *Forceful *Does vomiting relieve pain? *What started first: Vomiting or pain? (If V 1st --Infection/ If Pain 1st Surgical) BOWEL CHANGES: *When was the last bowel movt? *Any abdominal distension? *Is there any blood in stool/Dark stool? *Are you passing any gases? APPETITE CHANGES: Sx Dehydration: *Dizziness *Dark Urine LAST MEAL: *Did you eat alone? *Was there anything new? * Did others have same Sx? RISK FCTS: *Any Past H/o Abdominal Surgeries * Crohn’s disease? * Groin surgery(hernia repairs) * Gall Bladder stones? * Pancreatic stones * Diverticulitis? *Smoking *Alcohol

CONSTITUNIOL Sx: Fever/Chills/wt loss/Lumps 7 bumps CVS: Chest Pain/Hd/HTN FH; Ca Colon/Polyposis PAST Medical h: Meds: Aspirin/OTC/Herbals/LMP

71F/Abd pain after meals x 4 weeks [10 min H]



(ischemic) Dd: 1.GERD 2.PUD 3.Gastric Ca 4.Ischemic Mesentry 5.Pancreatic failure 6.Ischemic colitis Here Pt was concerned that spouse died of Ca Stomach.Reassuare her that unlike Flu Ca Stomach is not contagious, but because they were married for so long there might be a chance that they were exposed to a risk fct.But you will conduct a thorough History & Inv

OCD

PQRSTUV A&A Assoc Sx: •Constitutional Sx: •GI Sx: *N/V/D *Malena *Bowel movts * Abdominal bloating • Cardiac Sx: *Chest Pain/Palpitations/SOB RISK FCTS: HTN/DM/Smoking/FH of HD/Cholesterol?HD If +ve for HD •Ascertain type & when diagnosed,enquire abt F ups •When/what & if intervention PMH: •Any meds/OTC/Herbal •Hospitalization & Surgery FH Social H: Here since Pt had Cardiac Sx.Your cardiac history is of concern to me & I’ve to do a PE & perform some blood inv & an ECG & then ask for a Surgical Consult

DIARRHOEA



Bloody Diarrhoea: Awakens at night? Any constant pain? Think Inflammatory bowel disease

Always ask about antibiotic use: if yes: 1.Why 2.Which Ab 3.For how long 4.When In acute Diarrhoea look for dehydration In ch diarrhoea look for Wt loss & then dehydration

Bad Diarrhoea if: +ve for fat droplets Floats Undigested food Bulky

After intro: OCD Frequency COCA + Blood Impact PAIN ASx D/d: 1.GE: if fever/N/V 2.Travel 3.New restaurant 4.Antibiotic 5.Osmotic PMH Fh Sh

24 yr old diarrhoea x 3 days

Introduction: Tell me more about is since the moment it all started? O C: How often do you go to the wash room? Estimated amount of stool passed? Is it Tarry? Mixed with blood? Any undigested food? Bulky? Is it offensive? Does it float in toilet bowl? Is it difficult to flush? A&A Did you try any meds/did they help

ASx: Do you feel dizzy/Thirsty? Do you drink enough fluid? Have you lost wt? Do you have any additional Sx like abdominal pain? Does bowel movt relieve your pain? N/V CSx: Did you eat in a new place? (raw food----Shigella) Did you recently take any antibiotics? Anybody else in the family has diarrhoea? Any FH of Bowel disease? Or condt called Crohn’s Disease? FH SH

24 yr M Diarrhoea x 6 weeks (Crohn’s) Can you tell me about it? O C: All the day?/At night/ D COCA + Bl

Bulky

+ Fat droplets Floats & difficult to flush Undigested food PAIN Relieved by diarrhoea or not Distension/gases U: How has it affected your life How do you deal with it? V: CSx: Extraintestinal Sx: Skin rashes/nail changes/Joint pains/back pain/Hx of psoriasis/Back pain/red eyes/Morning urethral discharge/ D/D: Thyroid :tremors/sweating Relation of diarrhoea to food like dairy products Travel or camping history Sx of Liver disease FH of Ulcerative colitis/Crohn’s SH

DIARRHEA x 6 wks



(Irritable bowel disease)

Dd:

1.IBD 2.Infection: camping/travel 3.Hyperthyroidism 4.IBS 5.Lactose intolerance 6.Coeliac Disease 7.HIV 8.Ch Liver & pancreratic failure OCD COCA + Blood + mucus PAIN:if +ve which started first Pain or diarrhoea Does bowel movement relieve the pain? Does it awaken you at night? Do you feel you want to go back to wash room again? Distension/gases U What made you come in today?

V:

DIET: dairy products C Sx: In IBS R/o Organic cause: Stress? What type; Family/Job How do you cope with it? How is your mood/Interest? FH: of Ca Colon at young age SH

42 M with Bld work LFT INCREASED:



ALT:300 AST:100

Cc: Bld works Intro Talk about blood works: 1.WHY? 2.Is it 1st time 3.When 4.Who 5.If done before: what were results then?

SPIKE EXPLAIN Results CONSEQUENCES: Sx. Ac & Ch CAUSES OF LIVER DISEASE: PMH FH SH

Intro: As I understand you’re here today to discuss some of your blood tests results Is it 1st time/ Why/who/When EXPLAIN: Results show that there is an increase in the markers to measure the function of the liver, called liver enzymes, this indicates that there is an injury to the liver cells There are different causes, but before coming to the causes, I want to know if there are any Symptoms of liver disease Ac Sx; 1.Yellow discoloration of skin/eyes 2.Pale stools/Dark urine 3.Itchy skin 4.Loss of appetite/nausea/distaste for cigarettes 5.Flu like Sx few weeks ago Ch Sx;

CAUSES OF LIVER DISEASE

1.Have you ever been diagnosed as liver disease before? 2.Have you ever ben screened for liver disease before? 3.Have you ever been vaccinated for Hepatitis A or Hepatitis B before? TRANSITION I want to ask qns now as to whether you were exposed to liver disease: 1.Do you smoke? Take alcohol/Recreational drugs? Past use IV drugs 2.Tattoos 3.Any past surgeries/hospitalizations 4.FH of liver disease 5.Long term disease in past 6.Any H/o bleeding disease Thank you for all this info

Need to do some further assessment

52 M/Dysphagia x 6 wks ----5 mins H



D/d: 1.Oesophageal Ca 2.Scleroderma 3. O.Stricture 4.O. 5.DES 6.web/Ring 7.HIV

FIRST CLARIFY: If difficulty to initiate swallowing or food coming out from nose ---- Neuro Sx/Stroke/MS Pain on swallowing ------ AIDS/CMV/Ca/Decreased immunity/Leukemia If food gets stuck -> Can you show where it gets stuck?

ONSET:How did it start? COURSE: Intermittent /progressive Intermittent for both solids & liqds ----> SPASM Intermittent for only SOLIDS---------------> Oesophageal web/ring check by endoscopy Progressive: Starts with fluid & Solids later ------>Achalasia & Scleroderma Progressive: Starts with solids & later liquids ------> M/Canical obstruction: Ca Here initially you could flush it down with water, but unable to do so now

ASSOC Sx:

N/Vx Repeated chest infections Chest pain/Tightness in chest Do you bring up undigested food? Cough Change in voice GI Sx: Abd pain/Abd distension Change in bowel pattern Any blood in stool or vomit? CONST Sx: Fever/ Night sweats/Change in appetite/Chills /Lumps & bumps If wt loss,how much Wt loss over how long? Tiredness *Mets: Liver: Yellow discoloration of skin/Dark urine & pale stools

RISK FCTS: I’m going to ask you a few qns to reach the diagnosis: 1.Any H/o heart burn? 2.Have you ever been diagnosed with a condt called GERD?----If Yes:

How long ago?

Did you seek medical attention? Was an endoscopy performed (A tube with a camera put down your food pipe to view) 3.Were you ever diagnosed with a condt called: Barret’s Oesophagus? 4.Do you smoke?/Drink alcohol? 5.FH of Oesophageal Ca 6.H/o swallowing acid or alkalies 7.H/o Chest radiation 8.H/o Achalasia 9.Any skin tightness 10.Change in color of digits when exposed to hot or cold enviorenments 11.CNS: H/o stroke/weakness H/o DM H/o HIV

Chest Pain 45 M x 6 wks



GERD ONSET: When did you first notice it? How did it start? What were you doing at that time? Course: 1.Is it the same intensity it was at the beginning? 2.Is it increasing in intensity? 3.Is it decreasing in intensity 4.Is the frequency increasing or decreasing or same? Duration: Foe how long now you’ve the pain? POSITION: Can you tell me exactly where it hurts you?

Quality

Can you describe the nature of your pain? Burning,Tightnes.... Radiation:

Does it move anywhere else in your body? To the (L) arm,Jaw,Neck,Back? S

everity: On a scale of 1 –10 ...... How has this pain affected your life? Time Does it occur at a particular time? Does it awaken you at night? Aggravating fcts: 1.Exercise/Stress 2.Food: (peppermint,fatty food,Citrus fruit) 3.Tobacco 4.Alcohol 5.Hot or cold food Relieving fcts: 1.Antacid 2.Elevation of head end of bed Assoc Fcts: Do you have 1.Heart burn 2.Acid reflux 3.Difficulty swallowing 4.Dark stools?

5.Cough 6.Hoarse voice 7.Sore throath 8.Wheezing 9.Dental problems (dental erosions)

10.Palpitations 11.SOB/PND/Orthopnea

12.Constitutional Symptoms: 13.Loss of appetite & Wt loss 14.Fever & Chills 15.Lumps & bumps 16.Lupus To gain more insight into your condition, I need to ask you some details about your life: Do you smoke Drink Alcohol *** ? Recreational drugs? Do you eat a lot of fatty foods? How soon afer dinner do you go to bed?

PAST Med H 1.Are you on any medication/ 2.Do you take Aspirin or any pain relievers or any OTC products? 3.Is there any herbal medication you’re on? 4.Are you allergic to anything? 5.Have you ever been diagnosed to have a High BP or high BSL? 6.Have you ever had a heart attack or stroke? 7.Were you ever hospitalized? 8.Did you ever undergo any surgical procedure?

FAMILY History Social History

MGment: Nonpharmacologic Choices •Dietary modifications (avoid chocolate, caffeine, acidic citrus juices, large fatty meals) •Weight loss if obese (BMI > 25 to 30 kg/m2) •No snacks within 3 hours before bedtime •No lying down after meals •Reduce alcohol intake •Elevate legs under the head of the bed on 10 to 15 cm blocks •Stop smoking •Avoid tight clothing

Pharmacologic Choices

When possible, eliminate drugs that impair esophageal motility and lower esophageal sphincter tone (e.g., calcium channel blockers, theophylline, tricyclic antidepressants, beta-blockers, anticholinergic agents).

6th Feb GU If CC Urinary Sx: I.Obstruction II.Irritation III.Urinary changes OSTRUCTION 4 qns: 1.Difficulty initiating urine ----->Do U need to strain? 2.Did you notice change in stream? 3.Dribbling? 4.After passing urine, do you still need to pass more? IRRITATION: 1.How many time do you need to go to Wash room: Now,Before At Night? 2.Does it affect your sleep? 3.Do you feel you need to rush to WC 4.Are you able to make it in time? 5.Have you ever lost control? 6.Burning sensation 7.Flank pain 8.Fever URINE CHANGES: COCA + Bld Consistency,remember: 1.Frothy urine 2.Cloudy urine 3.Not clear urine

67 M ER reten48 hrs/Colleague passed F Catheter & got 1.2 L urine



As I understand, you’re here today because you’d difficulty in passing urine since 24 hrs.& one of my colleagues has passed a Foley catheter & drained 1.2L urine. HOW DO YOU FEEL RIGHT NOW? I’m glad to know you’re better If Pt c/o pain: Bear with me few minutes as soon as I finish with asking you a few Qns I will deal with it. Can you tell me about it since it all began?

OCD -------- U V

How many times did you try to void? Were you able to pass any amt? Is it the first time/Can be first time to this extent Recently have you noticed any changes in your urine?you.g: Do U need to rush? When did it first start?

From that time till now, is it Increasing/Decreasing? • Sx of Obstruction: 1.Difficulty initiating urine ----->Do U need to strain? 2.Did U notice change in stream? 3.Dribbling? 4.After passing urine,do U still need to pass more? EMPATHY •Sx of irritation: 1.How many times do U need to go to Wash room: Now, Before At Night? Does it affect your sleep? 2.Do U feel U need to rush to WC Are you able to make it in time? Have you ever lost control? 3.Burning sensation 4.Flank pain 5.Fever •Urine changes: COCA + Bld Ask if H/o passing stones in urine C Sx: ASx: Trauma to back:Back pain Sx of GU: asked in earlier Qns Mets to Liver: Sx of Liver Disease Mets to lung: Cough/Haemoptysis Mets to CNS:

RISK FCTS: 1.Have you ever been screened or diagnosed as prostrate disease? 2.Have you ever done the blood test for PSA 3.FH of Ca Prostrate: Who & at what age? 4.Do you smoke 5.Take alcohol 6. How is your diet?

D/D: 1.Are you on any medications? 2.Do you take psychiatric medications 3.Meds for Glaucoma? 4.H/O Stroke 5.H/o Urethritis 6.Sx of renal failure: Puffy face, swollen ankles

PMH: Since this is the first time I’m seeing you, I need to ask you some qns regarding your Past Medical History: Do you have DM/HTN Hospitalized or had any surgeries? SOCIAL H:

67 M brought in by daughter,as she is concerened that he is not himself



Greeting: As I understand .......... Whenever a pt is brought in by someone always ask:DO U AGREE? If Yes:...I’m glad you’re here as we can find a working solution If NO: I would appreciate that you’re here just to make you daughter happy, I promise you I will be as fast as I can.

Tell me more about the concern: She is worried that I’m not going out as I used to before. Do you stay at home? I’m not going away to far places or out with my friends When did this happen? Do you share her concern? My daughter overreacts I’m Glad you’re here What prevents you from going out? GIVE CONFIDENTIALITY I wet myself When How many times? How did you react at that time?

The go to Urine History: Obstructn/Iritation/Urine

If Pt does not divulge, Go to Geriatric History: 1.What Medications?do you take & ask to see list or bag of meds Do you take sleeping pills (specifically ask for that as it affects memory & gait)OTC/Herbal products 2.Screen for Mood & Memory 3.Vision & Hearing/Balance & Falls 4.Urine: Retention in males & Incontinence in females 5.Sleep: How many hours 5.1 When do you go to bed? 5.2 Do you get up frequently? Follow event.......... If still refuses to talk,do review of Sx

67 M Dark urine x 1 week (H x 5 min)



D/D: 1.Bleeding/SE of warfarin 2.PSGN 3.Stone 4.Nephrotic syndrome 5.Renal or bladder Ca 6.Trauma 7.Berger’s disease 8.Infection

If CC is Dark Urine, make sure it is haematuria & not Jaundice What do you actually mean? Dark like Tea/Cola or Red? OCD O:Sudden/gradual C: from that time till now,is it: Off & on or continous/Same D: Has it ever happened before? P Does it occur at the: 1. Beginning of stream?(Urethra) 2. End of the stream? (bladder) 3. Whole of the stream? (Kidney) V: Urine changes:COCA + Bld Consistency,remember: 1.Frothy urine 2.Cloudy urine 3.Not clear urine Obstrn 1.Difficulty initiating urine ----->Do you need to strain? 2.Did you notice change in stream? 3.Dribbling? 4.After passing urine, do you still need to pass more? Irritation: 1.How many time do you need to go to Wash room: Now,Before At Night? 2.Does it affect your sleep? 3.Do you feel you need to rush to WC 4.Are you able to make it in time? 5.Have you ever lost control? 6.Burning sensation 7.Flank pain 8.Fever

C Sx: ASx: 1.Back trauma 2.H/O recent Sore throat or skin infection If yes to sore throat: When was that/Was there swelling of feet/Puffy face? 3.H/o bleeding tendencies or blood thinners If Yes to blood thinners: Which one/Why/How long/How much do you take/When was last F/U/what was your last INR/What is the target/Any new medications/Any antibiotics? 4.Did you notice bleeding from any other sites? Gums/Nose/Malena/CNS:Numbness,weakness,difficulty finding words ...... 5.H/o stones

Neuropathic Pain



Neurologic Disorders: Neuropathic Pain

Table 1: Types of Neuropathic Pain Peripheral Neuropathic Pain Central Neuropathic Pain • Nerve root pain • Central post-stroke pain • Carpal tunnel syndrome • Spinal cord injury pain • Trigeminal neuralgia • Brain injury • Postherpetic neuralgia • Multiple sclerosis • Incisional neuralgia • Syringomyelia • Nerve trauma (causalgia) • Phantom limb pain Investigations History with attention to: otemporal profile and characteristics of the pain ofunctional status, mood, quality of life, insomnia, sexual function, previous and current treatments, especially concurrent medications opresent or past chemical dependency, especially if opioids are considered • Physical examination: odetermine areas of sensory loss (hypoesthesia) and skin sensitivity characteristic of neuropathic pain determine other neurologic findings that might indicate a progressive lesion requiring imaging and surgery odetermine concurrent conditions that contribute to the pain problem, e.g., concomitant muscular pain and psychological factors • Other investigations: oimaging with CT or MR scanning if a space-occupying lesion is suspected o electromyography odiagnostic sympathetic blockade if complex regional pain syndrome is suspected o although there is no established therapeutic range, monitoring serum levels of tricyclic antidepressants (TCAs) and antiepileptic drugs may help to assess adherence and guide dosage Guideline for Use of Opioids in Chronic Nonmalignant Pain •Consider after other reasonable therapies have failed. •Perform a complete pain and psychosocial history, physical examination and appropriate diagnostic tests. A history of substance abuse, tension-type headaches, frequent migraine headache, muscular pain (myofascial pain, fibromyalgia) or pain that appears to be largely determined by psychologic factors is a relative contraindication to the use of opioid therapy. •A single physician/prescriber/pharmacy is optimal. The prescriber may choose to set up a contract with the patient. The agreement should specify the drug regimen, possible side effects, the functional restoration program and that violations may result in termination of opioid therapy. •The opioid analgesic of choice should be administered around the clock and may include a provision of “rescue doses” for breakthrough pain. Controlled-release preparations include morphine, oxycodone, hydromorphone, tramadol and transdermal fentanyl. Avoid meperidine primarily because of accumulation of its excitotoxic metabolite normeperidine. Codeine is a poor analgesic for moderate to severe pain because it has to be metabolized to morphine. Drug administration should include a titration phase to minimize side effects. If a graded analgesic response to incremental doses is not observed, the patient may not be opioidresponsive, and opioid treatment should probably be terminated. •The patient should be seen monthly or more often for the first few months and every 2–3 months thereafter. At each visit 1.assess pain relief (0–10 scale), 2.mood, 3.side effects, 4.quality of life, 5.adherence to functional goals and 6. presence of drug-related behaviour. Optimally, affix a copy of the prescription and drug therapy flow sheet to the medical record. •The goal of opioid therapy is to make the pain tolerable. For some patients with chronic noncancer pain (e.g., postherpetic neuralgia), the administration of an opioid analgesic can mean the difference between bearable and unbearable pain. Therapeutic Tips

•Two to three months constitutes a reasonable trial of medication for neuropathic pain. •While patients frequently say they have used amitriptyline or carbamazepine or other agents, these drugs have often been used in too high or too low a dose and for too short a period of time. It is useful to re-institute these drugs to evaluate their effectiveness when used appropriately: start low, go slow, increase dose until relief of symptoms or side effects occur and treat side effects when possible. •Be sure the patient understands the goals of therapy: reduction in pain from moderate or severe to mild, at the price of some side effects that may be tolerable or treatable. •Use a pain assessment tool, such as a scale of 0–10 where 0 is no pain and 10 the worst pain imaginable, to evaluate pain with and without activity, and before and after medication. •As a matter of course, prescribe an artificial saliva mouth spray with TCAs and a stool softener with TCAs or opioids. •Use controlled-release formulations of carbamazepine and opioids •It may be possible to reduce or gradually withdraw medication after initial control of pain and a period of relief of 1–3 months (pain such as postherpetic neuralgia may resolve spontaneously and trigeminal neuralgia may go into remission). Gradual reduction is important to avoid withdrawal symptoms. •Always consider combining pharmacotherapy with appropriate psychological and physical measures. •Try different drugs within a class (e.g., a TCA or a gabapentinoid such as gabapentin or pregabalin), drugs of different classes and combination therapy (polypharmacy) for a possible additive or synergistic effect; do not combine TCAs with SNRIs. •If opioids are used, guidelines are important and should be worked through with the patient. •A trial and error approach of scientifically unproven treatments is reasonable if standard therapy fails. •Repeated visits can provide important psychological support and hope for desperate patients as trial and error approaches are utilized. •If chronic neuropathic pain is being managed in general practice, semi-annual or annual visits to a pain specialist (where available) help provide support to the family practitioner for contentious approaches such as opioids, and offer the chance of a novel therapy for the patient

HEADACHE



Dd: 1.Tension H 2.Cluster H 3.Migraine 4.Temporal A 5.Cervical Spondylitis 6.Meningitis 7.SOL 8.SAH 9.Depression 10.Spousal abuse

Red Flags for Serious Headache 1. Age of onset Middle-aged to elderly patient 2. Type of onset Severe and abrupt 3. Temporal sequence Progressive severity or increased frequency 4. Pattern Significant change in headache pattern 5. Neurologic signs Stiff neck, focal signs, reduced consciousness 6. Systemic signs Fever, appears sick, abnormal examination Caution: If headache does not fit typical pattern, a serious diagnosis can be missed. ***** Chronic Daily Headache & Medication overuse Headache

Chronic headache occurs daily or almost daily for 15 days per month, for 6 months or longer. The most common causes of these headaches are transformed migraine and chronic tension-type headache. In the former there is history of migraine attacks and over several years the migraine attacks become more frequent. Soon the migraine characteristics give way to chronic daily headache with a daily or near-daily background headache that often resembles a typical “tension-type headache.” People with chronic tension-type headache may have no history of distinct migraine. Patients with these disorders frequently use excessive amounts of abortive agents, including ergots, acetaminophen, ASA and opioid analgesics. They can have rebound headaches as a result of medication-overuse, while some may have symptoms of depression or other psychological comorbidities. Rebound headaches can also occur with the overuse of triptans. Most will improve in days or a few weeks with the discontinuation of these medications, especially mixed analgesics. Generally, simple analgesics should be used less than 15 days per month in primary headache disorders such as migraine or tension-type headache or they will lead to the development of medication-overuse headache and chronic daily headache. Further, if chronic daily headache develops, other useful abortive and prophylactic medications usually have less efficacy. Management includes recognition of these disorders, tapering and stopping the offending agent(s), and starting a prophylactic medication such as amitriptyline or another agent listed in. During withdrawal, particularly in patients with transformed migraine, use abortive agents such as DHE or a triptan for treatment of the migraine headaches that emerge. Short-term admission to hospital may be required to use the Raskin protocol (using DHE) and give support. If psychological comorbidities such as depression are present, they must be managed and treated. Consider referral to a multidisciplinary pain management clinic for cases failing to respond to therapy. Therapeutic Tips •Give abortive treatment, without exceeding recommended dosages, as soon as possible. •Use simple analgesics less than 15 days per month, and ergots, triptans, opioids or analgesic combinations less than 10 days per month. •A calendar or diary of headaches is useful in follow-up assessment. •Keep a record of medications (usefulness, dosage and side effects). •If migraine that does not respond adequately to symptomatic therapy occurs more than 3–4 times per month, try prophylactic medications for several months and then discontinue if possible, to assess ongoing need.2 •Different medications may need to be tried, including different members of the same class, such as triptans. •Follow-up is most important in managing chronic headache. •Reassurance and explanation are most important to the patient in the long term. •Always offer hope to patients with chronic headache even if no cure is available; most primary headaches can be controlled.

ACUTE HA x 10 days: 67M in ER



HISTORY: OCD PQRSTUV Onset: Sudden Vs Gradual Course: •All the time •Is it increasing or decreasing or is it the same? •VARIATION: Did you notice any variation? •Is it the same throughout the day •Does it awaken you at night? (EMPATHIZE++++) Duration: •How long the whole disorder •How long each attack • How frequent: off & on Posn: •Unilareral/Bilateral • Where is it exactly? •Does the part where it hurts is tender (Temporal Arteritis) & do you feel like a cord-like structure there? Quality: •Throbbing •Burning •Tightness/Pressure • Ice pick like Radiation? front,side,back of head,or in the eyes,ears or throats? Severity: On a scale of 1 – 10 Can you say It is the worst HA of your life? Timing Triggers:(not when single episode) U: Qns for empathy** • How has it affected U in your daily life? • How r U coping with it? • How do U feel abt it? • What r your expectations from today’s visit?

V= deja Vu Has it happened before? Aggravating factors: •Eating (Jaw claudication) •Bending forwards/Coughing/Lifting/Lying down (Inc ICP) •Lights/Certain foods etc (Migraine) •Eyestrain (vision correction) • Alcohol (cluster H) Alleviating fcts: Did you try any meds & were they helpful? Assoc.Symptoms: In addition to your headache did you notice any other symptoms: (Try & do constitutional sx first as you may forget them) Fever/Neck pain/Photophobia/Skin rash/Ear infection NEURO Screening: 1.Vision changes: What type of problem? 2.Hearing abnormalities 3.Difficulty swallowing 4.Weakness/Numbness 5.Difficulty finding words 6.Difficulty in balance or repeated falls 7.Changes n bowel/Urine Loss of bladder control 8.LOC 9.H/o Seizure

MOOD Changes MEMORY problem Changes in CONCENTRATION Has anyone told you that you’ve ben acting strangely?

MSK Screening Is there pain in your joints For how long? Can you raise your arms above your head?

H/O INJURY: To head Did you have a fall & hurt your head?

EXTRACRANIAL: EYE: Did you notice any redness or need eyeglasses? Sinusitis: Facial pain/flu Throath pain Dental pain

RISK FCTS: Do you smoke Take EtOh Take recreational drugs?

PMH: Have you taken pain killers,if +ve: How much & for how long (rebound HA) Did you take any OTC or herbal meds? Are you allergic to anything? Have you ever been diagnosed with HTN/DM/Stroke/MI/Ca? Were you ever hospitalized or underwent Surgery? FAMILY H: HTN/DM/Stroke/MI SOCIAL H: Who lives with you? How do you support yourself financially? DIAGNOSIS: Temporal Arteritis

24 M/HA 6 wks Office 10 mins H & C



Primary Headache Secondary Headache Type % Type % Migraine 16 Systemic infection 63 Tension-type 69 Head injury 4 Cluster 0.1 Vascular disorders 1 Idiopathic stabbing 2 Subarachnoid hemorrhage

Exertional 1 Brain tumor 0.1 Cluster headache is a rare form of primary headache The pain is deep, usually retroorbital, often excruciating in intensity, nonfluctuating, and explosive in quality. A core feature of cluster headache is periodicity. At least one of the daily attacks of pain recurs at about the same hour each day for the duration of a cluster bout. The typical cluster headache patient has daily bouts of one to two attacks of relatively shortduration unilateral pain for 8–10 weeks a year; this is usually followed by a pain-free interval that averages 1 year. Cluster headache is characterized as chronic when there is no period of sustained remission. Patients are generally perfectly well between episodes. Onset is nocturnal in about 50% of patients, and men are affected three times more often than women. Patients with cluster headache tend to move about during attacks, pacing, rocking, or rubbing their head for relief; some may even become aggressive during attacks. This is in sharp contrast to patients with migraine, who prefer to remain motionless during attacks. Cluster headache is associated with ipsilateral symptoms of cranial parasympathetic autonomic activation: conjunctival injection or lacrimation, rhinorrhea or nasal congestion, or cranial sympathetic dysfunction such as ptosis.

OCD ONSET: If pt says this time was worst: Ask Prev episode,if present: 1.How long ago? 2.Did you seek medical attention then? 3.What was the diagnosis? 4.What Rx was given? 5.Is this current HA different from from the previous one? NOW GO to THE CURRENT HA. Finish with the current HA & can go back to previous HA ONSET:Gradual/Intermittent COURSE: Inc/Dec/Same DURATION: How Often? How long does each episode last? Everyday,few hrs,wkends longer& awaken at night? POSN QUALITY: R S T U V AlLEVIATING FCTS: Sleep/Pacing/Dark room/Lying down

AGGRAVATING FCTS:

•Flashing lights •Lack of sleep •Certain food •Alcohol (Cluster ) CONSTITUTIONAL Sx Fever/chills/N Sweats/Loss of appetite & loss of wt/Lumps or bumps anywhere TRAUMA: RISK FCTS: Are you under stress? How do you handle stress? Do you Smoke?...... Do you take Alcohol: How much How long Why?? Have you used recreational drugs? How is your MOOD? Any chance that you may be depressed? *MI PASS ECG Mood: Interest Psychomotor retardation Appetite Sleep Suicidal ideation Energy Concentration Guilt If M& I are +ve Look for depression

PMH: Are you taking any meds?/OTC/Herbal products? Were you ever Diagnosed with HTN/DM/Ca Were you ever hospitalized or had surgery? FH: SOCIAL HISTORY: Who lives with you? How do you support yourself financially?

Acute Attack Treatment Cluster headache attacks peak rapidly, and thus a treatment with quick onset is required. Many patients with acute cluster headache respond very well to oxygen inhalation. This should be given as 100% oxygen at 10–12 L/min for 15–20 min. Sumatriptan 6 mg subcutaneously is rapid in onset and will usually shorten an attack to 10–15 min;. Sumatriptan (20 mg) and zolmitriptan (5 mg) nasal sprays are both effective in acute cluster headache, offering a useful option for patients who may not wish to self-inject daily. Oral sumatriptan is not effective for prevention or for acute treatment of cluster headache. Preventive Treatments The choice of a preventive treatment in cluster headache depends in part on the length of the bout. Patients with long bouts or those with chronic cluster headache require medicines that are safe when taken for long periods. For patients with relatively short bouts, limited courses of oral glucocorticoids or methysergide (not available in the United States) can be very useful. A 10-day course of prednisone, beginning at 60 mg daily for 7 days and followed by a rapid taper, may interrupt the pain bout for many patients. When ergotamine (1–2 mg) is used, it is most effective when given 1–2 h before an expected attack. Patients who use ergotamine daily must be educated regarding the early symptoms of ergotism, which may include vomiting, numbness, tingling, pain, and cyanosis of the limbs; a weekly limit of 14 mg should be adhered to. Lithium (600–900 mg qd) appears to be particularly useful for the chronic form of the disorder. Table 15-9 Preventive Management of Cluster

Headache

Short-Term Prevention Long-Term Prevention Episodic Cluster Headache Episodic Cluster Chronic Cluster Headache & Prolonged

Headache Prednisone 1 mg/kg up to 60 mg qd, tapering over 21 days Verapamil 160–960 mg/d Methysergide 3–12 mg/d Lithium 400–800 mg/d Verapamil 160–960 mg/d Methysergide 3–12 mg/d Greater occipital nerve injection Topiramatea 100–400 mg/d

Gabapentina 1200–3600 mg/d

35F HAx 6 wks H & C



Can you tell me abt it since you first noticed it? I’m glad you came in today,do you have the HA now?Any particular reason as to why you came in today? OCD Empathize+++ PQRSTUV CONSTITUTIONAL Sx Local Sx: RISK FCTS: Smoking/alcohol/recreational drugs PMH: •Are you on any medications • Are you on the Contraceptive Pill? •Was it changed recently? •Did you notice any relation to the HA & the Pill? •Any OTC/Herbal meds? •HTN?DM?MI?STROKE?CA? Any hospitalizations or Surgery? FH: Similar HA in any one of your family members? FH of HTN/DM/Stroke/MI SOCIAL H: Stress in your life? Who lives with you? Look out for Domestic Violence.... How do you support yourself financially? COUNSELLING: Migraine can be related to the pill Disct the OC or change the particular pill & switch to another form of pill or contraception like IUCD or barrier method o avoid triggers, especially in migraine, e.g., too much or too little sleep, irregular meals, lack of regular exercise, extremes of stress or relaxation, known dietary triggers o apply ice; sleep or rest in a dark, noise-free room DIAGNOSIS:MIGRAINE

45 M HAx 4 wks



OCD PQRSTUV This scenario Pt has typically gets HA at work,better at wkends & when he is drivng home. Alert to possibility to exposure to something at work. On H/o : •What sort of Job, he was a forklift operator. •Ask which sort of Environment he works whether it is: 1.Open or closed 2.Operated by electricity or gas 3.Presence or absence of ventilation 4.Presence of Carbon monoxide alarm,whether it has ben checked 5.If anybody else in the work place has a similar HA

40F/Looks older Weakness (R) arm x 6 hrs History x 5 mins & review of Sx



D/d: Vitamin D Vascular:Stroke/ICH/TIA INFECTION: Abscess/Meningitis/Encephalitis Traumatic: Head Injury Autoimmune:Vasculitis Metabolic: electrolyte abnormalities/Hyperthyroidism/Uremia Idiopathic:Syncope/MS Neoplastic: Mets or Pirmary Brain T Drugs: EtOH/Cocaine/Phencyclidene/Amphetamine

OCD: O: Sudden/Gradual What were you doing at that time it occured C: Is it getting worse? D:

PQRST UV Quality of defeciet: Sensory/Movt/Power 1.How weak is it? 2.Can you move at all? 3.Partially weak? U:How has it affected your life? (ADLs) Gross motor:(Reaching shelves/Opening doors) Fine Motor:Buttoning shirt/using keys/writing V: Have you had such episodes previously? OTHER LIMB: what abt (R) Leg/(L) Arm & (L) Leg

Assoc Sx: Local Sx: •Parasthesias/Pain •Calf Pain/Swelling •Recent travel/Immobilization CNS: HA/Dizziness/LOC/Visual disturbances (amaroux Fugax)/Slurred speech CVS: Palpitations/Chest pain CONST Sx: Fever/Chills/wt loss/Lumps & Bumps Trauma: or injury Bladder: any urinary problems (R/O MSclerosis) RISK FCTS: Smoke/Alcohol Was your blood ever checked for cholesterol & Sugar? ....... When/if on any Rx ......... OC DM/HTN/Stroke/Ca/MI Do you have a form of regular exercise?

PMH: •Are you on any Meds/OTC/Herbal products (particularly Asa/Warfarin/Blood thinners) •Do you have any allergies •Were you ever hospitalized or had any Surgeries? •Do you have any Peptic Ulcers

FH: Does anybody else in Family have such a condition HTN/DM/Stroke?MI SOCIAL H: Who lives with you? How do you support yourself financially?

Alteplase in Acute Ischemic Stroke: Treatment Criteria Treatment criteria 1.Ischemic stroke in a patient ≥ 18 years 2.Stroke onset > 1 h and ≤ 4.5 h before alteplase administration 3.Stroke deficit that is disabling or measurable on the NIH Stroke Scale 4.No intracranial hemorrhage on CT or MRI scan

Exclusion criteria 1.Time of stroke onset unknown or > 4.5 h 2.Any hemorrhage on brain CT or MRI scan 3.Symptoms suggestive of subarachnoid hemorrhage 4.CT or MRI signs of acute hemispheric infarction involving more than 1/3 of the MCA 5.History of intracranial hemorrhage 6.Stroke or serious head or spinal trauma within the preceding 3 mo 7.Seizure at stroke onset 8.Systolic blood pressure ≥ 185 mm Hg or diastolic blood pressure ≥ 110 mm Hg or aggressive treatment (intravenous medication) necessary to reduce blood pressure to these limits 9.Recent major surgery 10.Arterial puncture at a noncompressible site within the previous 7 days 11.Elevated activated partial thromboplastin time 12.International normalized ratio > 1.7 13.Platelet count < 100 × 109/L 14.Blood glucose concentration < 2.7 or > 22 mmol/L 15.Any other condition that could increase the risk of hemorrhage after alteplase administration

Alteplase in Acute Ischemic Stroke: Monitoring5 Blood Pressure and Neurological Signs •Baseline, then Q15min × 2 h after starting alteplase •Then Q30min × 6 h •Then Q1H until 24 h after starting alteplase •Call MD if the systolic BP is > 180 mm Hg or if the diastolic BP is > 110 mm Hg on 2 or more occasions taken 5–10 min apart •Stop the infusion, obtain emergency CT scan and notify MD if there is neurologic deterioration, severe headache, or new onset of nausea or vomiting Blood Glucose •Call MD if glucose > 12 mmol/L Lines and Tubes •Delay placement of nasogastric tubes, indwelling catheters or intra-arterial pressure catheters Medications •No ASA, ticlopidine, clopidogrel, heparin or warfarin for 24 h •Acetaminophen 650 mg po or pr Q4H if body temperature is ≥ 38°C or for analgesia •O2 via nasal prongs or face mask to keep O2 saturation > 90% •After the alteplase infusion is completed, continue iv normal saline (with or without KCl) Investigations • CT brain scan after 24 h Carotid endarterectomy (CEA)2 Patients with carotid territory transient ischemic attack or nondisabling stroke and ipsilateral 70– 95% internal carotid artery stenosis should be offered carotid endarterectomy within 2 weeks of the incident transient ischemic attack or stroke unless contraindicated. CEA is also appropriate for selected patients with moderate (50–69%) symptomatic stenosis. These patients should be evaluated by a physician with expertise in stroke management. Carotid stenting may be considered for patients who are not CEA candidates for technical, anatomical or medical reasons. Antiplatelet therapy

•If intracranial hemorrhage is excluded by CT scan, but alteplase is not indicated, give ASA 160 mg immediately. This is followed by ASA 80–325 mg daily. •When alteplase is used, wait until intracranial hemorrhage is excluded by CT scan 24 hours later and give ASA 160 mg once. This is followed by ASA 80–325 mg daily. •Administer ASA as a suppository or via nasogastric tube to dysphagic patients. Use enteric-coated formulation for patients who can swallow. No evidence supports the use of ASA doses greater than 325 mg/day for secondary stroke prevention. The GI side effects of ASA are dose related. •For patients who were taking ASA prior to their stroke, consider other antiplatelet agents, such as clopidogrel 75 mg daily or a combination of ASA and sustained-release dipyridamole 25/200 mg twice daily, although these regimens have not been tested in acute stroke. •The combination of ASA and clopidogrel is not recommended for long-term secondary stroke prevention. Anticoagulant therapy •Immediate systemic anticoagulation with unfractionated heparin, low molecular weight heparin, heparinoids or specific thrombin inhibitors is not recommended in the setting of acute ischemic stroke, not even for patients in atrial fibrillation (AF), because there is no evidence of short- or long-term benefit. Specifically, reduction in early recurrent ischemic stroke is completely offset by an increase in major intracranial and extracranial bleeding.18 •ASA is as effective as warfarin for secondary stroke prevention in patients in normal sinus rhythm, and does not require laboratory monitoring. •For patients in AF, use warfarin at a dose to maintain the INR in the range 2.0 to 3.0, provided there are no contraindications to anticoagulation. For patients who cannot take warfarin, use enteric-coated ASA 80–325 mg daily. •The best time to initiate anticoagulant therapy is unclear. For patients with minor strokes, start warfarin as soon as intracranial hemorrhage has been excluded by CT scan. For patients with major strokes, delay warfarin until a CT scan done about a week or two after the stroke has excluded hemorrhagic transformation of the infarct. Blood pressure lowering treatment Randomized controlled trials have not defined the optimal time to initiate blood pressure lowering therapy after stroke.19 Oral blood pressure lowering treatment should be initiated (or modified) prior to discharge from hospital in patients whose blood pressure is ≥ 140/90.

IV. Restore Function of the Individual •Outcomes are optimized by care on a stroke unit provided by a coordinated interdisciplinary team (Start rehabilitation as soon as the patient is medically stable. •Family and community supports are important for social reintegration.

Therapeutic Tips •The effectiveness of thrombolytic therapy with alteplase is exquisitely time dependent; delays of any sort should not be tolerated. A minority of patients present to hospital within the first 90 minutes of stroke onset, leaving limited time to act. Immediate contact with the patient, rapid triage, and (most importantly) staying with the patient continuously during the clinical assessment, CT scan, blood tests and consent procedures are vital in ensuring that the appropriate steps are being taken as rapidly as possible prior to alteplase administration. For example, it is not necessary to wait for hospital porters to take the patient to the CT scanner. •Determining the time of stroke onset is critical in deciding to use alteplase, but checking the clock is not a natural reaction in the setting of an acute stroke. Encourage patients and families to think of “time anchors” (e.g., what was on the radio or TV at the time, or at what point in the patient's daily routine did the symptoms first occur). •Patients with acute stroke are often unable to communicate. When possible, the next-of-kin should travel with the patient to hospital (or between hospitals if the patient is transferred) to provide collateral history and consent for treatment before the time window for intervention closes. •If the patient is referred to a tertiary care hospital, have the stat blood work (CBC, INR) drawn at the community hospital and the results faxed to the referral centre as soon as possible. •Point-of-care INR testing , if available, can provide results quickly. •Signs of infarction on a CT scan done within 4.5 hours of stroke onset are usually subtle. If the CT scan of a patient being considered for treatment with alteplase shows a very definite infarct in a location that explains the presenting clinical symptoms and signs, recheck the time of onset.

A 30 YOF with right arm weakness for 10 hours, Hx for 5m



Intro Where is your weakness? Can you still work with your hand or no? Do you have burning or tingling sensation on your hand or shoulder? How about numbness? Any problem on your right foot? Lt. arm or leg? Is it the first time? (If the patient says that she had it before than: “When was it? How long did it last? Which medication did she take?) Did you fall or lost your consciousness? Any change in your vision? Loss of vision? Double vision? Blurry vision? Any change in your hearing? Buzzing sound? Diffucult in finding words? Any change in balance? Any change in urination and bowel movement? When you bent your neck do you fill electrical shock along your spine? Do you difficult to swallow? Have you ever had dizziness, headlightedness, loss of consciousness, jerky movement, seizure? How is your mood / concentration / memory? Any change in your personality? When you touch your face do you feel any electrical shock? Uhthoff’s sign: when they get hot water or hot weather – trigger for their symptoms (especially optic neuritis). Review systems from head to toe: chest pain, heart racing, sob, cough and phlegm, abdominal pain, nausea and vomiting, joint pain, skin rash, diabetes, thyroid disease, anemia CSx RF for MS, PMHx, FMHx

PAEDS



1.Pediatrics (30) 2.Psychiatry (30) 3.Physical exam (30) 4.Management (12) 5.OBGYN ( 6.Communication Skills (10) 7.Counseling (10) 8.Medicine (CVS 15, Neu 15, Med 20)

Pediatrics Consider abuse There are no children in the room, only parents. Maternity leave – either husband or wifes.



A child 9m – chronic diarrhea



(CF, Celiac, HIV; Lactose deficien cy)

5y.o fever – take history



Skin rash – ask questions about it (distribution, relation to vfever) HSP

Son, 3y.o is coughing for 4wk and they want to renew his antibiotics



This shows there was a condition Ask What Ab,for which condt,When?. Don’t waste your time –R/O: Hyperactive airways or is it infection that has not cleared,or could be asthma.

A mother just delivers a baby who is IUGR all questions should about pregnancy and delivery



1.Reassure her, 2.Note appearance of the child 3.Note Paediatrician’s visit, 4.History of pregnancy/Obstetric History 5.Family history. In case mum was smoking,taking alcohol & drugs & asks if her fault if child has IUGR Don’t reproach her – it is NOT her mistake. It is a multi-factorial condition.Can be due to various causes,some genetic,pregnancy,related to baby Because safe levels of smoking,drugs & alcohol not known, We always recommend not to smoke or drink for futurepregnancies.

Parents are concerned that their child is not growing enough



[AGEx2+8] What his weight in birth. 14m 8Kg (birth weight 3.5Kg). He is underweight.

CC OCD COCA-B AA ASx PMHx SHx 0-6m: BINDE Birth – Pregnancy: Was it a planned pregnancy? 1.Did you have any regular follow-up? 2.Did you have any US? Was it normal or not? 3.During your pregnancy did you have any fever or skin rash? 4.Any contact with sick person or cats? 5.Any medication/smoking/drugs/alcohol? 6.Screened for HIV/Syphilis/GBS/Hepatitis B? Blood group? Birth – Delivery: 1.Was it in term or not? 2.What is the route? (Cs/NVD) 3.How long it took? (18hr is normal for primi, 12hr for multi), 4.Early gush of water? 5.Any need for augmentation? 6.What was the APGAR score? 7.Did the baby cry immediately? 8.Did your baby need any special attention? 9.Any bulging or bruising in his body? 10.When were you sent home?(C/S 3d, V/D – 1d). 11.After delivery did you have any fever/vaginal discharge/any medication? 12.Were you told that your baby had any congenital deformity?

Immunization – if he says that the child is not immunized you have to inquire for the reason. If he is not vaccinated because the parent is busy – look for child abuse RED FLAG.Ask wt & milestones If it is due to religion believe – you don’t have to ask more. Otherwise – ask about nutrition.

Nutrition – WEIGHT: 1.What his weight today, 2.Weight at birth, 3.Highest weight, Growth chart. X (birth), 5m-2x, 1y-3x, 2y-4x. Weight: Agex2+8 H (birth, about 50cm), 1y-1y, 2y-1.75H (half of his adult height), 4y-3.5H HC (at birth): 35cm What do you FEED your baby If formula: – When did you start the formula If B Fed at all Did you consider B feeding? what type of formula do you use? How do you prepare it? Was there any changes in the feeding? Did you add any solid food or supplements (any fortified serials or iron) do you feed him with any bread, solid food – when started the diarrhea (before the solid food or after?)

Development – At the end 1y they use words, 2y – two words at one sentence, 3y – 3words in one sentence; 4y – speak normally. Gross motor: role – 4m, seat- 6m, crowling – 9m, standing – 1y, climbing upstairs – 18y, riding bicycle – 3y

Environment – with whom do you live at home? Any other children? Relation between your child and other households? Who spends most of the time with the child? Financially how do you support yourself? Do you live in your own house? Do you have basement in your house? Anybody drinks or uses drugs? Building – basement (mold) and Old houses (lead poisoning). 6-12m: School Performance: comparing the grades between now and previous. >12-14 yrs: HEAADDSSS Home: with whom do you live? Education: Which grade? How are your marks? What do you want to be? Recent drop in grades? Activities: Any hobbies? (in case of epilepsy – ask for the risky activities) Alcohol: do you smoke, drink, (a lot of people of your age might experiment with drugs? How about you?), Smoking Diet: do you have any special diet? Drugs: have you ever tried recreational drugs? Smoke Sexual: are you in relationship? Suicide: how is your mood?

Questions for dehydration: Does baby have tears when crying? How many times you pee? How many times you change his diapers?

5 Day old infant with yellow discoloration since he was 2 days old



A mother who is after 5days from deliver (if she uses “jaundice” – what do you mean be that?). Is it early in the second day is it pathological. Late in the second day – it has no value. Make sure that the baby is stable – Red flags: 1.High pitched crying, 2.Poor feeding & Poor sucking 3.Floppy baby, 4.If above three are present, it is a problem, decide to reassure her or tell her you’ve to do a physical exam& admit If you have to take history and counsel ------>Reassuarence Only history-------->Pathological m/p it is not physiology

What is the name of your child? (He is yellow) Good you are here; I hope you can reassure you at the end. OCD Tell me more about it since the moment it started O: Is it early in the second day is it pathological. Late in the second day – it has no value C: D: Where did you notice it? Is it spreading? Did it reaches the legs? Is it getting darker? In addition to it did you notice any dark urine? Pale stool (in bliary atresia – pale stool from the beginning?) ASx: INFECTION: In addition to that did you notice any fever, cough, discharge from ear,discharge diarrhea, vomiting, foul smell urine, is he crying, is he floppy, is he sucking well, (RED FLAGS) Rash, Dehydration: how many diapers did he change, any tears Transition: I am going to ask you some questions to see if any conditions cause this issue back to your pregnancy FHx: of liver disease and blood disease. If she are concerned – why you are concerned (will he be mental retarded).

Child crying for the last 10d, 6w old, counsel Father



A child who’s with infantile colic. How do you feel when your child is crying. Crying child could be colic,screen for abuse,see how parents handle it The crying might cause abuse

Weight, dehydration, Start to observe the body language of the father. OCD O; At that time was there any illness,like fever,runny nose C; Off & On/all the time Every single day,every day,how many days/week also “is he crying during the night?” – how does it affect you and your wife?) Aggravating FCts: Any chance he is hungry? Any chance he is wet & neds a diaper change? Diaper rash? Any chance he is too hot or cold? Alleviating Sx: Do you soothe him/hug him/carry him & walk/take hime for a ride/listen to music? Do you burp him/rock him/Skhe him? If Yes: How many times? When was the last time? What happens to him when you shake him? Does he stop crying? Does he pass out? (Children at this age cannot express their discomfort& only means of communication is by crying“I am going to ask some questions to see if there is any reason for this crying?” ASx; INFECTION: Fever, sweating, tender points in his body Running nose, coughing, vomiting, discharge from his ear, yellow discoloration, fowel smell urine, GI does he have distension of abdomen Gases Does he draw up his legs & cry Any relation to feeds

BINDE (Partial) N 1st P Planned pregnancy, Reg F/u Was it term P Any illness Smoke/Drugs, Term, Complicated, Needed special attention, separation, any congenital abnormality Environment: financial how do you support yourself, any financial stress, with whom do you live, repeated visits to ER, anyone in home have psychiatric problems/drugs/alcohol, relationship with your partner PMHx – diseases, hospitalizations

Rita Gordon, mother of 5w who vomit for the last 10d



Pyeloric stenosis GERD Infection Alleric to milk overfeeding Not Pyloric stenosis If the colour of vomit is yellow or greenish discolouration Not projectile + Wt loss

GERD No wt loss at 6 weeks Wt loss at 18 mo due to anaemia,due to bleeding due to oesophageal bleeding

Confidential – give it early according to the cues. Depressed: after my son become vomit or preceding the vomit. Not reliable history.

CC OC fD O: C; Off & on/All the time How many/day Increasing/Decreasing or same? COCA±B Forceful Feed: Formula/Breast? COCA How much F do you give? & How much does he vomi t out? AA: Any particular posn improves it? ( GERd upright better) IMPACT: WT & Dehydration Do you feel he is still hungry after you feed him? How many diapers do you change,Now & at the beginning? ASx: wt & s/o dehydration Gerd – no weight loss Pyeloric stenosis – yellowish colour (ask specifically about the colour, relation to feeding – up to half hour can be related to PS, what about position, do you burp him?) ASx: Infection – any signs of infection BINDE: N 1st If formula fed? Did you change the Formula? Have you considered breastfeeding? Is there any reason not to breast feeding? Overfeeding – overweight Allergy – less likely if she uses it from birth Abdominal distended B PWas it planned pregnancy Were there regular F/u? How do yu feel about being a mum? MOOD & INTERSET Any chance of being depressed? Any chance you feel like harming the baby or yourself? Do you have any support at home? “I see you are preoccupied / overwhelmed” Child abuse/neglect If there is a growth chart – it it is from the beginning. 4 min on the child, last 1 min to concentrate to the mother.

Sandra Bullock, 19 y.o, 8m child, pale



Intro Name of the child CC: Anemia ? OCD IMPACT Causes: Red Flags (bleeding & BINDE) Past MH FH ENv: Old house Pale – what do you mean? Who told you that OCD

If told by another person/ If you think about it,any chance he was pale before that or just now?,& you were unaware I like to see how it has affected your son: IMPACT: Is he as active as before? Crawl? Playful as before? LOC? Heavy breathing? Stop to breath when you feed him? T: I’m going to ask you some questions that could be the cause of this? Asx: Infection: Sweat, Fever, Loose of weight, Painful points? Does your child have bleeding? Bruises? Coughing blood? Tarry stool? BINDE: N 1st What do you feed him? (B/F) Any solids /supplements P: Was it a term Preganacy? IMMUNIZATION: ENV: With whom do you live? Any financial concerns? Old/new home Do you’ve a supportive family? PMH: FH: Any bleeding disorder? Repeated lver disease Any gall bladder disease or splenectomy Certain blood disease are more common in particular parts of the world & for that reason I need to know your & partner’s ethnic background.

ANEMIA: 29/F MCV Inc (Counsel)



D/d:[TN10/H21] A. MEGALABLOBALSTIC: a)B12 defeciency: I. Diet (vegan) II. Gastric: a)Mucosal atrophy b)Pernicious An c)Post G-ectomy III. Intestinal Absorption a)Malabsorption (Crohn’s,celiac sprue,pancreatic disease) b)Stagnant bowel (blind loop,stricture) c)Fish tapeworm d)Resection of ileum b)Folate deficiency I.Diet II.Intestinal malabsorption III. Drugs/Chemicals: a)Alcohol b)Anticonvulsants c)Methorexate d)Birth control pills IV. Inc demands: V. Pregnancy/Hemolysis/Hemodialysis/Psoriasis c)Drugs (Methroxate,azathioprine) B.Non Megalobalstic: I.Liver disease II.Alcohol III.Hypothyroid IV.Myelodysplastic syndromes Start By saying: I’ve the results of your test with me & before I proceed I need to get some information abt you that will help me understand: If Pt asks if Serious: STOP & ask WHAT is her concern. There can be many reasons for this result,though most are simple,however some can be serious, 2QNS: 1.What is the reason for doing the test 2.Is it the first time? Then explain the results

•Search for the cause of iron deficiency, including very careful consideration of occult gastrointestinal bleeding •Menorrhagia must be convincing before it is accepted as the sole cause of iron deficiency. This may be an opportunity for early recognition of a gastrointestinal malignancy—don’t miss it! •A reticulocyte response should be evident within one week of beginning iron therapy, with subsequent improvement in the Hgb of about 10 g/L every 7–10 days. •If the Hgb fails to respond as anticipated, consider that there may be: oongoing blood loss ouse of other medications that impair iron absorption oa different or concurrent cause of anemia and/or an impaired erythropoietic response o compliance issues •Gastrointestinal side effects are the most common reasons for non-compliance: ouse a graduated approach to dosing. Begin with a single tablet taken after a meal. On a weekly basis, as tolerance permits, add another tablet until the patient is taking one dose with each meal. Thereafter, gradually shift the timing of the doses to the beginning of meals osmall oral doses may be adequate in patients that are susceptible to gastrointestinal upset. In the elderly, daily doses of elemental iron as low as 15 to 50 mg are effective in the treatment of iron deficiency anemia9 In pregnant women, 20 mg/day of elemental iron, started at 20 weeks' gestation, is sufficient to prevent iron deficiency11 oiron contained in enteric-coated tablets is poorly absorbed. These products should be avoided •Some physicians replenish iron stores while others prefer to stop therapy when the Hgb normalizes, so that further blood loss will not be masked by robust iron stores. As a compromise: ocompletely replenish iron stores when the cause of iron deficiency has been identified and corrected odo not replenish iron stores when investigation has failed to

Therapeutic Tips •Search for the cause of iron deficiency, including very careful consideration of occult gastrointestinal bleeding •Menorrhagia must be convincing before it is accepted as the sole cause of iron deficiency. This may be an opportunity for early recognition of a gastrointestinal malignancy—don’t miss it! •A reticulocyte response should be evident within one week of beginning iron therapy, with subsequent improvement in the Hgb of about 10 g/L every 7–10 days. •If the Hgb fails to respond as anticipated, consider that there may be: oongoing blood loss ouse of other medications that impair iron absorption oa different or concurrent cause of anemia and/or an impaired erythropoietic response o compliance issues •Gastrointestinal side effects are the most common reasons for non-compliance: ouse a graduated approach to dosing. Begin with a single tablet taken after a meal. On a weekly basis, as tolerance permits, add another tablet until the patient is taking one dose with each meal. Thereafter, gradually shift the timing of the doses to the beginning of meals osmall oral doses may be adequate in patients that are susceptible to gastrointestinal upset. In the elderly, daily doses of elemental iron as low as 15 to 50 mg are effective in the treatment of iron deficiency anemia9 In pregnant women, 20 mg/day of elemental iron, started at 20 weeks' gestation, is sufficient to prevent iron deficiency11 oiron contained in enteric-coated tablets is poorly absorbed. These products should be avoided •Some physicians replenish iron stores while others prefer to stop therapy when the Hgb normalizes, so that further blood loss will not be masked by robust iron stores. As a compromise: ocompletely replenish iron stores when the cause of iron deficiency has been identified and corrected odo not replenish iron stores when investigation has failed to

32 M Fever & Tiredness x 6 wks ---- 10 mins focused History

3 Scenarios: H/O Splenectomy IV drug user Unprotected Intercourse

After introduction,Analyse Fever Constitunat Sx Then go to causes from Head to toe End with Liver Risk Fcts Travel Drugs PAST MH FH Social H (Which is linked to Risk Fcts)

Can you tell me more about your fever from the moment it started? O; Sudden/Gradual When it first started did you have any other illness? Did you seek medical attention then? What made you come in today? C; 1.Is it on & Off/All the time/everyday 2.Does it inc/Dec or is it the same? 3.Any variation during the day, like more in morning? Any particular patern? 3rd or 4th day or alt days 4.Did you measure it? 5.How often do you measure it? 6.Which was the highest temp? 7.Does it increase at night? 8.Did you take any meds?/were they helpful? 9.Is it the first time or have you ever had it before? 10.Anything increases or decreases it?

CONSTITIONAL Sx: Fever/chills/N Sweats/wt loss/Lumps/bumps

TRANSITION: I’ve to ask a couple of more qns to help me come to a diagnosis. If you’ve concerns at any time please tell me & I will answer them CNS: HA/N/Vx/Photophobia/neck pain/Neck stiffness Ear pain/Discharge from ear/runny nose/Facial pain/Sinusitis/Sore th/Difficulty swallowing Dental pain/Tooth ache CVS: H racing/Chest pain/SOB RS: Cough/Phglem/wheezing/H-maemesis Contact with TB/Have you ben screened for TB? GI Abd Pain/Diarrhoea/Malena GU Flank pain/burning urine/bld in urine/Inc freq in passing urine MSK Jt pain/Swelling/Skin rash/Ulcers in mouth/red eyes Have you ever been Dsed as a condt called Autoimmune Disease? Or has anyone else in your family been diagnosed? LIVER DISEASE: •Have you ben screened for liver disease? •Have you been vaccinated against Hepatitis A & B? •Sx of Ac Liver Disease: Yellow discoloration of skin & nails/Pale stools/Dark urine/Itchy skin •Sx of Ch L Disease: Inc abd girth/bruises /leg swelling/vomiting bld/memory changes

TRANSITION: I’ve to ask you some questions to see if you were exposed to liver disease without being aware of ,some of these qns may be personal, but it is imp that I ask them.All that you tell me is confidential & the information will not be released without your permission, unless I’m requested by law TRAVEL & CAMPING H Travel outside Canada H/o eating raw fish,raw shell fish.Have you visited a new restrauant? H/O Surgery/Hospitalizations Donated/recvd bld Tattooing/Piercings Smoke/Drink Alcohol/Recreational drugs? Any injectable drugs?

SOCIAL H: Whom do you live with? How long have you been with your partner? If for a specified time with a partner,ask if had any other sexual partners,though this qn is personal,I’ve to ask it as it is imp: When was the last time you’d sex with another partner/ Did you use a condom then? If YES: Ask Discharge/Lumps in groin/Genital ulcers How is wife:Does she have: Fever/Sx/Discharge? RISK FCTS: How do you support your self financially? Have you ben exposed to body fluids/TB H/Ca Any contacts with fever?

HIV SEXUAL HISTORY: Before marriage or before current relationship; 1.Did you have sexual partners? 2.At what age were you sexually active? 3.From that time till now, how many partners did you have? 4.Did you practise Safe Sex (Use of condoms?) 5. What is your sexual preference? M? F? Or Both? 6.What type of sexual activities do you prefer? Anal/vaginal/oral 7.Were you ever screened or diagnosed for STIs? 8.Did you have any sexual relationship besides your regular partner

Laboratory investigations: oHIV antibody test (repeat to rule out lab error) oplasma HIV RNA level (viral load) with the CD4 lymphocyte count is the best prognostic marker for progression to AIDS and survival. oviral drug resistance mutations become harder to detect over time. Therefore conduct a resistance test at entry into treatment program even if use of antiretroviral treatment is not currently contemplated2 oCD4 lymphocyte count and percentage is useful in determining where a patient lies in the continuum of HIV disease and the need for specific intervention (Table 1). Knowledge of the CD4 count can also help to narrow the differential diagnosis in a symptomatic HIV-infected patient. In adults, a CD4 count of 430 to 1360 cells/μL (0.43 to 1.36 Giga/Litre or G/L) is considered normal in most laboratories oscreen all patients for the presence of the HLA-B*5701 allele before starting or restarting abacavir.2 , 3 A positive result indicates a very high risk for severe allergy to abacavir and should be filed in the patient's chart operform a tropism assay to determine the chemokine receptor status (CCR5, CXCR4 or dual-mixed tropic) if considering use of the CCR5 inhibitor maraviroc. A plasma viral load of at least 1000 copies/mL is required to perform this test oCBC, differential and platelet count oliver (AST, ALT, GGT, LDH, CPK, alkaline phosphatase, bilirubin, INR, albumin) and renal (BUN, creatinine, electrolytes, urinalysis) profiles ometabolic profiles (fasting glucose and lipids—total cholesterol, LDL, HDL, triglycerides) ohepatitis B, hepatitis C, syphilis, cytomegalovirus (CMV) and toxoplasmosis serologies ocultures and smears for sexually transmitted diseases as indicated otuberculosis skin tests, sputum cultures and smears for mycobacteria as indicated o chest x-ray

Management of Patients with HIV Infection CD4 Count Action (cells/μL) At all levels • General counselling (safer sex, nutrition, need for follow-up, importance of adherence, etc.) •History and physical examination every 3– 6 mo •Plasma viral load and CD4 count at least every 3– 4 mo •Herpes suppression if frequent recurrences (more than 4–6 episodes per year) •Syphilis serology •Pneumococcal vaccine; hepatitis A and B vaccines if appropriate; update diphtheria, tetanus and inactivated polio vaccines as needed; consider annual influenza vaccinations •TB skin test and isoniazid prophylaxis if indicated (consider CD4 Count Action (cells/μL) repeating skin test yearly) < 500 • Plasma viral load and CD4 count every 3– 4 mo • Clinical evaluations and laboratory investigations at least bimonthly if symptomatic, diagnosed with AIDS, or on antiretroviral therapy < 200 • Start prophylaxis for Pneumocystis jirovecii pneumonia (PCP) < 100 • Start toxoplasmosis prophylaxis if seropositive and not on trimethoprim/sulfamethoxazole for PCP prophylaxis < 75 • Consider MAC prophylaxis < 50 • Screen by an ophthalmologist for early CMV retinitis (repeat at 3– 6 mo intervals) or consider CMV prophylaxis

Advise patients with HIV infection and immunosuppression that their risk of infections can be reduced by following good hygienic practices. 1.Ensure thorough hand washing after contact with potentially contaminated substances (diapers, soil, uncooked meat and produce) or handling pets 2.Avoid raw or uncooked meat and eggs, e.g., Caesar salad 3.Drink from treated water sources only 4.Avoid handling sick animals or pet (especially cat) litter 5.Avoid cat scratches and do not allow cats to lick wounds 6.Avoid contact with reptiles

45M with tiredness x 6 weeks



As I understand you’re having Tiredness since 6 weeks, can you tell me more about it since it all started? Pt says he is concerned. STOP & ask about his concern. Pt says, he is also never been so tired before. Clarify: What do you mean about Tiredness? •Sometimes I do not feel refreshed after sleep. •Do you feel lack of energy? Like you cannot move your arm above your head.

The Statement: NOT REFRESHED ANYMORE points to an organic cause OCD + Relation to sleep +/- Mood If Mood Sx + ------ MOAPS If Organic cause ---- Red Flags OCD At onset you can ask if there were any flu-like Sx initially (Thyroiditis) •Do you sleep more •When do you go to bed? •Do you wake up in the middle of the night •Which time of day/Night do you feel most? •Ask Nature of work; If shift •With whom do you sleep? •Does your partner C/o you snoring or jerky movts of limbs? (Restless Leg) •Do you feel better in morning or evening(if tired in morning-->Depression If evening-------->Organic cause) •Depression 1st Low mood then tired •In organic 1st Tired the Low mood

11.Ask Constitutional Sx first: Fever/Wt loss/Night sweats/Chills/Lumps & Bumps Then quick review of Sx: 12.Cardiac: Chest Pain/SOB/Palpitations 13.Pulmonary: Cough/Wheezing/Phglem 14.GI: N/V Abnormal bowel movts/Diarrhoea/Malena/ 15.Liver: Dark urine/Yellow sclera/Abd pain/Loss of aooetite/Pale stool/Itchy skin 16.GU: Change in color of urine/Amt of urine/Cloudy/Frothy urine/Dysuria/Facial swelling 17.Anemia: Bleeding gums/Easy bruising/Malena/Haematuria/Female: Meorrhagia & LMP 18.Autoimmune Disease: Joint Pains/Skin rashes/Oral Ulcers 19.Endocrine: Thyroid: Feel hot/Cold Skin Moist/Dry/Tremors/Wt loss If Pt has thyroid Sx,ak if on Thyroxine When Dsed If thyroxine levels are monitored? 20.DM: Risk fcts: FH & Lifestyle Once Pt has DM in history, GO over ALL Sx & Sy:

RISK FCTS: 7.Diet 8.Exercise 9.FH 10.Smoking 11.Alcohol 12.Recreational drugs

PAST MEDICAL HISTORY: Any medications/OTC/Herbal/LMP Surgery/Hospitalization FAMILY HISTORY: DM/HTN/Stroke/MI

SOCIAL H: Habits With whom do you live? How do you support yourself financially?

Hypothyroidism (underactive thyroid) is a condition in which your thyroid gland doesn't produce enough of certain important hormones. Hypothyroidism upsets the normal balance of chemical reactions in your body. It seldom causes symptoms in the early stages, but, over time, untreated hypothyroidism can cause a number of health problems, such as obesity, joint pain, infertility and heart disease. The good news is that accurate thyroid function tests are available to diagnose hypothyroidism, and treatment of hypothyroidism with synthetic thyroid hormone is usually simple, safe and effective once the proper dosage is established. Back to Content NEEDLE STICK INJURY Michael Jackson, Nurse in hospital, Needle stick 20min ago; History and counsel, 10min Variations: Janitor who was pricked in junk yard (here touch TT prophylaxis) 0.3% - HIV; 3% HCV; 30% HBV “The treatment will be the same no matter what is the situation of the other patient...” Did anybody talk to him? Did he accept to get his HIV status? “By law we are not allowed to take his blood without his consent”

QUESTIONS RELATED TO EVENT:

1.Size of needle 2.Blunt/hollow 3.Any blood on it 4.How deep was the injury? 5.What was gauge of needle? 6.Where was the location of the prick? 7.Any bleeding after that? 8.Whether he was wearing gloves? 9.What measures did he take? (Wash hands?) 10.Is it the first time? If Pt insists on doing HIV testing of the contaminated pt: I know it is of great concern about the pt’s HIV status, however from the ethical point of view we cannot do the HIV test without the pt’s consent. I can go after our interview & personally request him If Still he insists or ask for CD4 count: How do you think this will help us? It is a reasonable way of thinking. There are different conditions reflecting CD4 count & ethically not the right step We do it to obtain Pt’s information & not for the best interest of the pt However whatever the CD4 count it makes no sense in our management. We’ve to follow protocol: RISKS Give him the risks of being infected with N Stick injury: HIV------->0.3% Hepa C----->3% Hepa B-------> 30% .” In order to know what is the best line for you I need to ask you more questions. Do you know what the chances for getting infected are? (Out of 1000 people – only 3 will be affected). ASSESMENT: Being a health care provider – 1.Have you been vaccinated before for Hepa A & B 1.1How many doses? 1.2When was the last dose? 2.Liver Disease: Have you ever been yellowish? Itchiness? Dark urine? Pale stool? Btuises in body? C Sx: Repeated infections? Chronic diarrhea? Have you been screen for HIV or HCV? I am going to ask you some questions if you were exposed before for any of the viruses mentioned above 1.Any travel outside Canada? 2.Any surgery 3.Any blood transfusions/ 4.Tattoos/Piercings SH With whom do you do live. For how long have you been together

COUNSELLING:

Whenever we face such a situation,we’re faced with three possible infections that could be transmitted: HIV------->0.3% Hepa C----->3% Hepa B-------> 30% Good news – HBV high risk but good plan; we are going to measure the titer of antibody in your blood. If Okay,you need not worry,if low you may need an Immunoglobulin or revaccination What do you know about HIV. If infected,some bcome carriers,not all develoe into AIDS,we will screen you today: For screening you we need to sample today to have base line. Most of the patients don’t react until 6wk, few until 6m – we have to take it in these times. If at the end of 6 mo tests come back negative, you’re cleared If not you’re infected Other options: we will also refer you to occupation clinic – Who will start you on prophylaxis treatment. It consists of three medications usually. They will explain to you which medication and describe the SE. It will decrease the chances by ...% HCV – This is of concern as We don’t have prophylaxis yet there is more than 50% to be carrier, more than 50% of them become chronic, 50% of them will get cancer. However certain medications might help like Interferon & Anti retrivirals

“How do you feel about it?” Sometimes patients are overwhelmed and might harm yourself or others” From now till the results of your blood tests: Practise Safe sex Do not donate blood Joint a support group.” I wii file an incident report.”

35y.o, male, counselling about HIV test Wants to do HIV test as his partner has tested =ve



As I understand you’e here as you want a blood test.Can you tell me which blood test you specifically need? Can you tell me what made you come in today? **PT: I feel I’m at risk screen me for disease We cannot order all bl works, we’ve to look for a specific disease e.g: for TB we do a CXR/DM BSL/HIV Bl tests ** My Partner has tested for HIV + EMPATHY: I’m sorry, when was that? How is she doing now? How long have you two been together? How has it affected you? How do you feel? This can be a difficult for you, & you’ve done the right thing,& definitely we can arrange for a blood test “20 years ago we had no options, now even if you are positive we will have treatments and prophylaxis.” In order to get the diagnosis we need to do more questions.” 1.“Have you ever been screened for HIV”or HCV If Yes: When & where? 2.Any Sx OF HIV CSx, Mouth, Ulcers,difficulty swallowing RS;Cough ,Diarrhea, Discharge,Ulcers,Skin rash/yellowish, Dark urine/Pale stool I am going to ask you some questions if you were EXPOSED BEFORE for any of the viruses mentioned above 1.Any travel outside Canada? 2.Any surgery 3.Any blood transfusions/ Tattoos/Piercings? SEXUAL HISTORY Relationships now and before / Sexual predilection / Sexual practice When were you sexually active? How many partners have you had? Did you practise safe sex? PMH Any long term disease/hospitalization/allergies/medications

COUNSELLING “What do you know about HIV?” “Nowadays we have better control over the disease. Once they start get the infection they called AIDS patients.” “HIV is a virus which affects our immunologic system. It is different if you are the carrier as oppose to have symptoms when you are an AIDS patient. HIV is a virus. HIV attacks the immune system itself - the very thing that would normally get rid of a virus It takes around ten years on average for someone with HIV to develop AIDS ” Is that reasonable? Am I clear? Do you have any questions? In order to know whether you are infected or no we need to do a blood work. We need your consent for that. They will give you the results within two weeks. If the results are positive – they will call you back. If it negative – they will not call you. Options to send the sample: Nominal – with your name Non-nominal – put a bar-code (the public health and the doctor will know the identity) Anonymous – put a barcode on the sample and only you know the results (needs a lot of counselling. “How do you feel about it?” Sometimes patients are overwhelmed and might harm yourself or others” From now till the results of your blood tests: Practise Safe sex Do not donate blood Joint a support group.” I like you to know that in 2011 there are a lot of options open, with Rx it is controllable & people can live with it for a long time. If you test positive you’ve a have legal obligation to inform your partner.

37y.o, Male, HIV results came back and are positive



Divide time: 2min telling the results, 3min assessing symptoms, 2min explain about the virus, 3min the plan HIV treatment in Ontario is covered. “Nice to meet you. Or Hello” Because this is the first time I see you I am going to ask you some questions, to get a better understanding of your results: “Why/Who/Is the first time/When you did it?” ** Somebody I knew died from it last week “Who is the person that you got it from him?” (nature of the relationship) “People don’t get it from normal daily contact. Was there any direct contact?” SPIKE Setting

Perception – what do you know about HIV? ―What did you think was going on with you when you felt the lump?‖ ―What have you been told about all this so far?‖ “Are you worried that this might be something serious?” Invitation – how much details you want me to discuss? DO you want someone else to be present? ―Are you the kind of person who prefers to know all the details about what is going on?‖ ―How much information would you like me to give you about your diagnosis and treatment?‖ “Would you like me to give you details of what is going on or would you prefer that I just tell you about treatments I am proposing?” Knowledge ―Unfortunately, I’ve got some bad news to tell you, Mr. Andrews.‖ “Mrs. Smith, I’m so sorry to have to tell you….” Empathy – “What are your expectations from this visit?” If he is not very anxious you might take some time until giving him the results. Otherwise you give them immediately. “I wish I’d better news for you. Unfortunately the results came back and I am very sorry to tell you that the result is positive.” Silence. Wait x 10 sec if he cries “How do you feel right now?” Do you need more time/ Do you need water? Do you want me to proceed? **If mistake? “Whenever we do a screening test we confirm it if it positive. So the result is very accurate.” The initial test is ELISA & then we do a confirmatory test called Western Blot Part of F/u atre other tests like the CD4 count & Viral load

SOCIAL Hx: We will ask you several questions concerning your sexual partners. Drug use Asx: CSx: AIDS Sx: PMH: any long term disease? HTN/DM? Any hospitalizations/Surgeries? If does not want to inform his wife From experience it is not necessarily that your partner will leave you. From that reason we need to inform your wife. Part of the public health job is to tell her. The same measures we are taking for you we should do for her. It is better that she will know it from you rather than from the Public Health – otherwise she’ll loose the trust in you. Do you have any symptoms relating to HIV? PMHx and drugs. COUNSELLING If asked what he knows about HIV – don’g repeat. Otherwise you explain here. From HIV+ to AIDS. Significance of CD4 and Viral load: Viral load,amt of HIV virus existing in your body, lower the viral load,& higher the CD4 count, better condition We should think about HIV these days like a chronic disease as DM or HTn,it can be controlled but not cured. Part of your treatment is to refer you to HIV clinic – they will treat you based on these parameters. The newer medications are effective and control your disease – however they have side effects. How’s your mood, how you feel about that, there are a lot of support groups. I’ll give you “hot lines” number. From now on you have to practice safe sex & do not donate blood

In case of the resident who was asked to backup his supervisor orthopaed 1.I am competent – to emphasize 2.Short term – we don’t have time so we need to see her urgently 3.Long term – solve the situations that it wouldn’t occur again Dr. Smith, Chief of staff of the hospital, ask another doctor to talk with the doctors me because they smell alcohol from the doctor. You smelled like alcohol. People have different ways to relieve their stress – how do you relieve your stress? Team worker – interpersonal relation It is better to provide prescription than getting pregnancy “I may share your point of view – that doesn’t say it gives me the right to impose my beliefs.” My concern is if we face the same situation in the future...what will we do? Why won’t we contact the College? Don’t give any names. In case of report – it should be reported to the college. “We are here to help you. Moving to new place can be stressful. The reason of this meeting we have received two complaints – they claimed they have smelled alcohol from you. Is that happened? If you don’t mind me asking few more questions: do you drink more, or you did it on lunch time? Before working here – where else did you work? Did you ever have a complain about drinking? I would recommend that you will contact the program for doctors who drink. They will suspend your license. After stop drinking you will resume your work. At the end you will have your career back.

24M: HA 6 wks ER 10 mins H & Counsel



OCD PQRSTUV INC ICP: •SOL: Brain Tumors •Mets •Infection •Toxoplasmosis HA + Inc ICP Constitutional Symptoms: fever: Always ask what came first: fever or headache * If primary tumor; FH of Malignancy H/o Cancer,Leukemia,Melanoma H/o HIV: •Ask if HIV status known, • Have you ever been checked? •I’m concerned because of the risk factors involved IF HIV status known ask: •When was the last time you saw your Dr • What was the last CD4 count • Are U on any Anti AIDS meds? •TB Skin test results •Syphillis tst results •Date & results of PAP’s smear

*Ocurence f opportunistic infections,malignancies, *STIs: Hepatitis B & C,Syphillis,Gonorrhoea,Chlamydia,Molluscum contagious *Other bacterial infections,fungal infections,Malignancies * Travel History,illness while away & use of preventative vaccines * Medication History: *Antiretroviral History (including response,CD4,Viral load) adherence,toxicity,any resistance testing & results If HIV or AIDS & not on meds: Asses condt by asking: Constitutional symptoms: •Fever •Repeated chest infections •Cough thrush •Odonophagia •TB •In Female: Cx al Ca

OCD ONSET: COURSE: When Pt says HA now Ct ous Ask: •When did it become constant? •In beginning how often did you have it? •What time of the day? •Is it more in the morning? Or is it worse in the evening? •Does it wake you up? DURATION: PQRST UV S: How was it in the beginning as compared to ‘Now’ U Qns for empathy** • How has it affected U in your daily life? • How r U coping with it? • How do U feel abt it? • What r your expectations from today’s visit? Aggravating fcts: Coughing/leaning forwards/lying down Alleviating fcts:

ASOC Sx: CONstitonal Sx: Fever/nightsweats/chills (if before headache indicates patho) Ask when Wt loss started LOCal Sx: NEURO Screening: 1.Vision changes: What type of problem? 2.Hearing abnormalities 3.Difficulty swallowing 4.Weakness/Numbness 5.Difficulty finding words 6.Difficulty in balance or repeated falls 7.Changes n bowel/Urine Loss of bladder control 8.LOC 9.H/o Seizure MOOD Changes MEMORY problem Changes in CONCENTRATION Has anyone told you that you’ve been acting strangely? H/O INJURY: To head Did you have a fall & hurt your head?

EXTRACRANIAL: EYE: Did you notice any redness or need eyeglasses? Sinusitis: Facial pain/flu Throath pain Dental pain PMH: RISK FCTS: Do you smoke Take EtOh Take recreational drugs? Route Tattoo

COUNSELLING: Do you have any qns for me? Based on what you’ve told me,the symptoms are concerning & I need to admit you today, as you’d stopped your meds, you may be exposed to an infection Your HA may be caused by this infection. I will refer you to an Infectious Disease Specialist Also do some blood investigations & Imaging of your head. DIAGNOSIS: CNS Toxoplasmosis in HIV +ve Male

22F sudden loss of vision x 2 wks seen by 2 drs one opthal



As I understand you’re here because you’d loss of vision in (R) eye x 10 days, I understand you’ve been seen by 2 Drs •What did the drs tell you? •What diagnosis did they give you? •Any investigations were done? •How’re you doing today/Tell me how it all began...... OCD

ONSET: Sudden/gradual What were you doing at that time? Anything particular happened at that time? Is the loss all the time or off & On? Ask a little about local Sx: Pain Photophobia/Injury U V SOCIAL H:

•Speak about confidentially here • Who lives with you? •What is your relationship? •Any difficulties in your relationship? Emphasize confidentiality • Was there a stressful situation before you lost your vision? •Let us go back to that day........ •Make sure no suicidal/Homicidal ideation COUNSELLING: This seems like a stressful situation for you & sometimes when we face such situations our brain finds it difficult to deal with it & this stress can be manifested by loss of function. In this case you saw something that made you lose your sight.It is not uncommon & called CONVERSION DISORDER I will refer you to a therapist to help you understand the stressor in your life & learn how to handle it. LOSS OF VISION: 32 M/F Pt presented with vision loss x 2 weeks OCD Onset after car accident Here enquire about the nature of accident Ask whether she or other driver was hurt & how is her driving now, does she still drive? Gradual C: Is it increasing now?/Same/Varies at certain times of day U &V CONSTITUNAT SX: Assoc Sx: *HA: Here +ve,OCD: PQRST: When does it occur? Morning or evening Vomiting +/Quality---- projectile Weakness/Numbness/Difficulty finding words ENDOCRINE: Thyroid Disease: feel hot/cold/Warm & moist skin/tremors Pituitary:Sometimes Pts in similar situations can notice breast engorgement & secretions from breast (For Males) & changes in sexual life ,desire & habits In Females ask directly about amenorrhoea galactorrhea SX of Acromegaly: Inc size of shoes/Tight ring FH of Kidney stone/Pancreatic Ca/Diarrhea/Foul smelly stools

Past H Fh Social H VISION LOSS 1.40 M difficulty in vision 2 wks 10 mins H & C 2.22F sudden loss of vision x 2 wks seen by 2 drs one opthal (Somatization GAO -207) 3.40M diificulty in vision x 4 wks seen by optometrist counsel All D/vision: Screening Qn: What do you mean? Pt will answer: I’m not seeing well Now ask close ended qns: 1.One/(B) eyes 2.Blurry V 3.Double vision: a.Relieved by covering one eye? b.Horizontal/Vertical/Oblique c.Worse in one direction of gaze? d.Fluctating or constant? (Gets worse at end of day) 4.Loss of vision 5.Curtain falling 6.Dark spots/flashes 7.Difficulty seeing on sides/when you drive do you have difficulty changing lanes? 8.Do you bump into objects when walking? 9.Do you see halo around objects? OCD: O;Suden/gradual Painless/Painful PAIN: Assoc with: • Blinking •Eye movts •HA/N/V •Brow/Temporal pain •Photophobia •Gritty sensation How has it affected your life Has it happened before? Asso Sx: Fatigue wt loss,joint SxNight sweats,ever Polyuria/poly dipsia Tingling /Numbness Past Occular H: Use of eyeglasses/Contacts: Duration H/O Occular surgery,Laser Rx,Infection,trauma,FB Presence of Ch eye disease: Glaucoma/DM PMH: Htn/DMMS/HIV Asthma Allergies Meds:Occular meds Current+Past

Somatization Disorder

22 YOF Somatization disorder 4-2-1-1 If seen by a surgeon – suspect somatisation. What did the surgeon tell you. OCD PQRST During the day or night. CSx

Jaundice, white stool and dark urine Foul smell, bulking, droplets Change in bowel movement First time to have this pain or had it before (V) MRI – why do you think it is important? Somatic pain disorder / Somatization Pains: headache, joints, back, pain with intercourse Sexual: You are here because you are concern. The pain you have, and multiple doctors – all these are consistent with somatisation. Once every 2-3weeks See Zu09: 207-8 Introduction to OBGYN OCD COCA +/- Blood ΑA ASx:– which organism MSGO PMHx OBGYN MAP CC Menses Gynecology history Obstetriscs h Sexual h VAGINAL DISCHARGE. OCD COCA ΑA AsSx – which organism MSGO PMHx

AMENORRHEA OCD MAGOS VAGINAL BLEEDING OCD COCA +/- Dc ΑA M ASx G O SHx PHx FHx

INFERTILITY I+O Tr Partner C M G S Intro How many months trying to conceive? If less than 35 y – wait for 1yr If around 40 – wait for 6m If greater than 40 – immediately O – if children from previous relationship Transition: ―In order for a couple to achieve pregnancy both partner involves should be relatively healthy and capable of having children. For that reason I need to ask questions about your and your partner’s health. Some of these questions can be personal, but important to ask, but I can assure that everything king is strictly confidential. The male factor is responsible for 40%.‖ COITAL H. How often do you have intercourse? Do you monitor tmp? MGOS All causes of secondary amenorrhea: Endometriosis Past medical history Family History Social history

MENSES Use the word ―period‖ 1.When was your last period? 2.Are your periods regular / not 3. How often? 4.How many days? 5.How many pads do you use/change? 6.Are the pads full? 7.How long does it last? 8.Are they heavy? 9.Do you see clots? 10.Between periods do you have spotting? 11.From your last menstrual period was your period different from the current one? 12.At what age did you start your periods? 13.Were they regular/irregular? 14.When did it become regular? 15.Are your periods painful / painless? 16.If irregular, from beginning? 17.Discharge – ask if pregnant and when LMP

GYENECOLOGY 1. Any history of Gyn. Disease – polyps or cysts 2. History of pelvic surgery (if yes – when?) 3.Have you used any birth control? When/type/any complications? 4.If less than 50 – have you ever done PAP (if yes – when and what were the results?) 5.If 50 and older – in addition ask for mammogram 6.If more than 65 – ask for bone density OBSTETRICS Have you ever been pregnant How many times, how about abortion and termination/ Abortion – termination medically; How many live children, what was the route, any complication? Were there any complications with the children? During pregnancy: any HTM/GDM/Vaginal bleeding How do you feel about (miscarriage?) If NULLIPAROUS:FH of HTN/DM?cong anomalies/repeatd C S/Twins

SEXUAL Hx: 1.With whom do you live? 2.How long have you been together? (a relationship below 6 month is not stable) 3.If you live alone – are you in relationship? 4.Are you sexually active? 5.Do you practice safe sex – using condoms? 6.When did you start to be sexually active? 7.How many partners you had last years? 8.What is your sexual preference? 9.What type of sexual activity do you practice? 10. Have you ever been diagnosed with PID 11.Any Vaginal discharge? 12.How about your partner? Does he have any symptoms have you ever been screned for HIV? PREGNANT IN T3: Reg F/U: No-----> Social Hx Yes:------->When If recent ask 2-3 qns about PET: 1.What was your BP 2.Was there swelling? MUM’s STABILITY: 1.Abd pains 2.Abd cramps 3.Vaginal bleeding or discharge 4.Any gush of water BABY: 1.Is baby kicking like before? 2.10 movts/12 hrs

19 year old with Vaginal discharge for the last 10 days History 5 minutes



VAGINAL DISCHARGE. OCD COCA ΑA AsSx – which organism MSGO PMHx: Recent use of Ab + DM

Intro: How can I help you today? O: Sudden(Allergey)/Gradual How did it start? C: 1.Is it all the time or on and off? 2.Is it increasing, decreasing or the same? COCA + BL 1.Can you estimate the amount for me?Do you use pads? How many? 2.How about the colour? Is it greenish, whitish or yellowish? 3.How about the consistency? Is it thick or watery? 4.Is the smell offensive? 5.Is this your first time? A & A:Does it increase after IC? I would like to ask you a few personal questions, hope you don’t mind? Sexual Hx: as part of A & A 1.Are you sexually active? 2.Any relation to your periods or with intercourse? 3.Do you have any pain with intercourse? 4.Any itching, redness, blisters or ulcers? U: V: Associated symptoms: LOCAL Sx: Pain with IC Itching/redness/blisters/warts/ulcers GU: Any burning in urination in urination? GI: Any change in bowel movements? PID : Any abdominal pain? If yes, then OCD, PQRST. :MSK: Any ulcers in mouth, difficulty swallowing, joint pain, skin rash or red eyes?

Constitutional Sx:

Menstrual Hx: 1.When was your last menstrual period? 2.Are your periods regular? 3.Was the last period the same as before? Gynecological Hx: 1.Do you use any form of contraception? 2.Have you had a pap smear? When and what was the result? Obsteterics Hx: 1.Have you ever been pregnant? 2.Have you ever had an abortion or miscarriage? Sexual Hx: As I understand you’re in a relationship… How long? Do you practise safe sex? Does the partner have any urinary symptoms,discharge? Before this? What age were you sexually active? How many partners in last one year? PMH:Since it is 1st time I’m seeing you,I need to ask some qns about PMH: SHx:

RX: Infectious Diseases: Sexually Transmitted Infections

Table 1: Differential Diagnosis of Vaginal Discharge1 , 2 Candidiasis Signs/symptoms: Trichomoniasis Bacterial Vaginosis Pruritus + + – Odour – + + (fishy) Discharge white, clumpy & curdy off-white or yellow, frothy grey or milky, thin, copious Inflammation + Simple tests: + – pH < 4.5 > 4.5 > 4.5 "Whiff" testa – Microscopic findings: +/- + Specific budding yeast, psuedohyphae motile trichomonads clue cells,b predominant Gramnegative curved bacilli and coccobacilli PMNs ++ +++ – Lactobacilli + – – a. Malodour often intensified after addition of 10% potassium hydroxide (KOH). b. Clue cells are vaginal epithelial cells covered with numerous coccobacilli. Back to Content 36 weeks pregnant with vaginal bleeding for 2 hrs History 5 min

Differentials: 1.When did the bleeding start? 2.How long has it been? 3.Were the pads fully soaked? Any clots? 4.What were you doing at the time? 5.Any H/o trauma? 6.Did you have any abdominal pain? If yes: •Did the pain start first or the bleeding? •Are you having any pain now? •OCD, PQRST 7.Any gush of water? 8.Are you under regular F/U? 9.When was the last F/U ? If missed, why? 10.Symptoms of pre-eclampsia: a.Weight gain? b.Headache? c.High blood pressure? d.Flashing lights or disturbance in vision? e.Swelling? 11.Stability of Mother: .........................? Have you had an U/S? When was the last one? # of babies? Position of placenta? Amount of fluid? 12.Stability of fetus: Is your baby kicking like before? Obsteterics Hx: 1.Have you ever been pregnant? 2.Have you ever had an abortion or miscarriage? 3.Any complications during previous pregnancy?

39 year old with vaginal bleeding for 50 days History 5 min OCD + COCA +/- Discharge AA ASx: M G O S Risk Fcts: GPOS D/d: PMH Fh SH

INTRO:

1.What made you come here today? 2.Did you seek medical attention before? OCD: O: How did it start? What were you doing at the time? Did it start gradually or suddenly? C: Is it on and off or all the time? Is it increasing, decreasing or the same? COCA Can you estimate the amount for me? Foul smell? A&A: Is there any relation to periods or with intercourse? Menstrual Hx: 1.When was your last menstrual period? 2.Are your periods regular? 3.Was the last period the same as before? 4.Can you differentiate this bleeding from periods?

I’m going to ask a few qns to see how it has affected your life: IMPACT: Are you having any dizziness? Hrt racing? LOC? Associated symptoms: CSx: Local & Mets 1. Local symptoms: Any itchiness, redness, discharge, pain during intercourse? Itching/rednes/blisters/warts 1. Any abdominal pain? When was your last Pap’s smear? What was result? O Sexual Hx: 1.With whom do you live? 2.Are you sexually active? D/D; Hypothyroidism Bl thinners Bleding disorders PMH FH of Ca

AMENORRHOEA 22 yr old Female



PEP: 1.what is your Ds? 2.What is your inv? 3.What is your Rx?

Always R/o pregnancy Intro: As I understand you’re here today because you did not have your periods since last 6 mo….. Can you tell me more about it? CC-------> When was your LMP? Any spotting in between? Let us talk about your periods from the beginning…….. 1.When did you have your 1st period? 2.Was it regular from the start? Or was it irregular? 3.When did it become irregular? 4.When your periods were regular,How often did they come? 5.How long did each cycle last? 6.When irregular,How often did they come? How many days did they last? 7.When periods were regular, were you using any contraception? If Yes: How long? When did you stop?(if Inj Depo provera I yr post injection amenorrhoea OC can be upto 6 mo Amenorrhoea) With whom do you live? Are you sexually active? Any chance that you may be pregnant? Ask Sx of pregnancy: •Breast tenderness •N/Vx •Increased visits to washroom OB Hx: Any time you were pregnant? Any abortions or miscarriages? RISK FCTS: I’m going to ask you questions to help reach what could be the cause HYPOTHALAMIC: 1.Are you under stress? 2.Are you losing wt? 3.How do you perceive yourself when you look into the mirror? 4.Do you exercise excessively? PITUITARY: 1.Any change in vision/Any difficulty in seeing on sides or changing lanes when driving? 2.Discharge from nipples & breast engorgement? THYROID: 1.Do you feel hot when others around feel cold or do you feel cold when others around feel cold? 2.Do you have constipation/Diarrhoea? OVARIAN: PCO: 1.Any acne 2.Increased facial hair? 3.Are you concerned about your weight? 4.Are you trying to lose weight? 5.Is there h/o DM? (ask for Sx of DM) 6.Any FH of PCOs or infertility? Premature Ov Failure: 1.Hx of Chemotherapy/Radiation to pelvis 2.Hot flushes 3.Night sweats Ovarian tumors: 1.Increased muscle bulk 2.Change in voice C Sx: Gyn Hx: Sexual Hx; Any H/o STis PMH: Since it is 1st time I see you,do you have any H/o HTN,DM Have you ever seen a psychiatrist before or used antipsychotic medications/



31 year old woman with 36 weeks pregnancy:BP155/110 Urine Protein +++



Intro: As I understand…..,you’re here today for a F/u visit,& nurse measured your BP & did a urine test.I’ve your results here & will discuss them with you, But I need to ask you some qns to gain a better insight into your condition 1.Were you ever diagnosed with increased blood pressure prior to this pregnancy? 2.When was your last F/U visit? 3.What was your Bp the last time? 4.What about your blood tests? 5.Were you anemic? Based on your BP & urine, these results are consistent with pregnancy induced HTN,& I need to ask you qns,to see if you’ve Sx pertaining to that. It could be a serious condition 1.Do you’ve H/O: HA ---------> OCD 2.How is your Vision ------------->Do you see flashes of light/Blurring 3.CNS --------> Weakness/numbness 4. Nx/V/Chest pain/SOB 5.ABD PAIN? 6.Bruises on body? 7.Yellow discoloration OF SKIN/ITCHINESS/Pale stool/Dark Urine 8.Swelling feet/Tight shoes/Rings tight 9. Difficulty opening eyes in morning/Inc wt gain 10. Vaginal bleeding/Discharge? • When was the last US: 1.How many babies 2.Is the baby kicking When is the due date? Have you been pregnant before? PMH FH of PET

COUNSELLING: Do you like me to explain it to you? It is a very serious condition What do you know about it? Preeclampsia is a condition of pregnancy marked by high blood pressure and excess protein in your urine after 20 weeks of pregnancy. Preeclampsia often causes only modest increases in blood pressure. Left untreated, however, preeclampsia can lead to serious — even fatal — complications for both you and your baby. Preeclampsia develops only during pregnancy. Risk factors include: 1.History of preeclampsia. A personal or family history of preeclampsia increases your risk of developing the condition. 2.First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy or your first pregnancy with a new partner. 3.Age. The risk of preeclampsia is higher for pregnant women younger than 20 and older than 40. 4.Obesity. The risk of preeclampsia is higher if you're obese. 5.Multiple pregnancy. Preeclampsia is more common in women who are carrying twins, triplets or other multiples. 6.Prolonged interval between pregnancies. This seems to increase the risk of preeclampsia. 7.Gestational diabetes. Women who develop gestational diabetes have a higher risk of developing preeclampsia as the pregnancy progresses. 8.History of certain conditions. Having certain conditions before you become pregnant — such as chronic high blood pressure, migraine headaches, diabetes, kidney disease, rheumatoid arthritis or lupus — increases the risk of preeclampsia. Most women with preeclampsia deliver healthy babies. The more severe your preeclampsia and the earlier it occurs in your pregnancy, however, the greater the risks for you and your baby. Preeclampsia may require induced labor and delivery by Caesarian section. Complications of preeclampsia may include: Lack of blood flow to the placenta. Preeclampsia affects the arteries carrying blood to the placenta. If the placenta doesn't get enough blood, your baby may receive less oxygen and fewer nutrients. This can lead to slow growth, low birth weight, preterm birth and breathing difficulties for your baby. 1.Placental abruption. Preeclampsia increases your risk of placental abruption, in which the placenta separates from the inner wall of your uterus before delivery. Severe abruption can cause heavy bleeding, which can be life-threatening for both you and your baby. 2.HELLP syndrome. HELLP — which stands for hemolysis (the destruction of red blood cells), elevated liver enzymes and low platelet count — syndrome can rapidly become life-threatening for both you and your baby. Symptoms of HELLP syndrome include nausea and vomiting, headache, and upper right abdominal pain. HELLP syndrome is particularly dangerous because it can occur before signs or symptoms of preeclampsia appear. 3.Eclampsia. When preeclampsia isn't controlled, eclampsia — which is essentially preeclampsia plus seizures — can develop. Symptoms of eclampsia include upper right abdominal pain, severe headache, vision problems and change in mental status, such as decreased alertness. Eclampsia can permanently damage your vital organs, including your brain, liver and kidneys. Left untreated, eclampsia can cause coma, brain damage and death for both you and your baby. 4.Cardiovascular disease. Having preeclampsia may increase your risk of future cardiovascular disease. Admit you …….. Stabilize you MgSo4 IV Labetolol May consider Steroids for babe Back to Content



REQ FOR CS



34 wks pregnant primi requesting for CS Intro: As I understand you’re 34 weeks pregnant & arte requesting a Cs. Before I proceed any further,I need to ask qns to reach the best plan. WHY? Pt: I believe it is painfull •What makes you believe it is painful? •Have you’d a prior experience? Pt: My sister had a NVD Never imply that sister did not receive best care There are 2 options: There are a lot of options to control pain nowadays & different people have a different pain threshold

•Are you on regular F/u? •Is it a planned pregnancy? •When was the last time you saw a doctor? if not on reg F/u as she is alone BF left etc always Empathize,Ask how she is coping with him leaving & how she is handling the stress How do you support yourself financially? I can see that this is a very difficult period & I want you to know that there are a lot of help & resources available in the community. I will make sure you’re connected to a social worker who will help you support you & your child & will help you to start your life

If on reg F/U •When was the last time you’d your BP measured? •Sx of PE: Any HA/Nx/V Blurry vision/Abd pain...... MUM’S STABILITY: Abd pain Contractions Vaginal bleeding Vaginal discharge BABY: Is baby kicking like before DUE DATE OBG Hx: Have you been pregnant before? How many times How about abortions/Mc If + •At how many weeks? •What reason •When •Any complications •How did you feel about that? PMH: Risk fcts NEXT come to PAIN CONTROL:

As I understand you want a CS,however if pain is a major concern, there are several options: You can attend antenatal classes that will teach you to breathe, meditate During your delivery a person will accompany you to give you support & emotionally support you If that does not work, there is another very popular method of delivery: EPIDURAL Anaesthesia ... explain.... An epidural block is a common type of anesthesia for labor and delivery. During labor, a needle is placed in the epidural space, which is just outside the spinal canal. A small, hollow tube called a catheter is inserted through this needle. Once the catheter is in place, the needle is removed and medication is injected through the catheter to numb your lower abdomen and birth canal. It may take 10 to 20 minutes to feel pain relief from an epidural block. As labor continues, the medication can be adjusted to help keep you comfortable. Painless & effective SE: rarely it may causeHa/Dizziness/infection & may prolong labour If still does not accept: What is your understanding about CS? It is a major surgery which is effective & lifesaving. However if there is no real indication,NVD is preferred as it is natural With CS there is a scar Longer recovery More bleeding Higher risk of infection Why don’t you think about it Give brochures Refer to Obstetrician for 2nd opinion F/U in 2 weeks

32F with 34 weeks pregnancy in hosp clinic,3yrs ago had an urgent CS due to cord prolapsed,needs her file,counsel her



See if request is logical Ask type of Cs Why not happy with last Cs May be bad experience pain/bleeding/Complications Maybe dead baby Was it 1st Cs or 2nd Was it CLASSICAL Cs? Then always Cs Risk of rupture of Classical Cs ------12% of which 10% will die LSCS risk of rupture is 1%

INTRO: As I understand you’re here cuz you want your file & based on your report you’d a hospital delivery because of cord prolapsed & it was an urgent Cs. Why? PT: Delivery by midwife who wants to look at it We will give you the file, but until then I want to discuss Pt: in a hurry Because you’ve had a previous Cs & you want a midwife. In order to make a proper decision you’ve some imp info to know What happened the last time? When did you know? How many week s were you? How did you feel? What was done? Did they explain it to you? Was there any bleeding/Infection How was the recovery period/ How is the baby/ Is it a boy/Girl How old? Is the baby healthy? If baby was fine & no complications: Looks like it was a right decision & the outcome was good What is your understanding about cord prolapsed? Cord is squeezed between head of baby & pelvic bones.It is a life threatening condition & needs urgent intervention

Have you ever been pregnant other times? How are you doing in this pregnancy? What was your last F/u Bp? US Baby kicking PMH Due Date

Waht is your understanding of Cs? There are different methods: Classical Section Vertical incision Lowere Segment C Section ----->transverse incision Most common is the transverse sectionThe cut is parallel to the fibres & thus it is a strong scar If you go into labour there is a lot of pressure & tension on the scar & with continuous pressure there can be rupture of scar this is concerning There will be a lot of bleeding we might not be able to help you & the mechanism of delivery will stop Chances of rupture in cl S is 12% of which 105 will die However if you want to continue the decision is yours Your life & the baby’s are endangered With a transverse Cs We can give you chance of normal delivery in hospital,as in case we need to do an urgent Cs we can If Not ConVinced: Why don’t you go back to your midwife & talk to her & mention She is trained & qualified We share the same guidelines We can arrange 2nd opinion F/U



54 year old female comes to clinic concerning about using HRT



When a patient has concern about any subject, address it very soon. Don't wait to the end. Dr: As far as I understand you're here as you have concern about using HRT. Patient: yes Dr. I feel I am confused about using HRT. Always ask what do you mean by HRT. So the patient will tell you how much they known about HRT. Dr: I'm glad you're here so we can discuss about it and address your concerns and hopefully by the end of the session you can make a decision regarding using HRT. Or hopefully by doing this discussion you will have a better understanding of HRT. Or you can say: I agree with you as there are a lot of confusion about HRT and the reason for this confusion is that in the past because it was used to be given routinely to all women who reach a certain age, however 10 years ago there was study called " women health initiative" in which the authors found that the numbers of the patients with serious side effects are very high. However those ladies used HRT for a long time. Serious side effects are Cancer, Heart attacks and Strokes. For that reason the routine use of HRT was stopped. Nowadays we have a better understanding and have better guidelines. Not only that we do it on the individualized basis. We use it only for short time, they don't exceed five years. So using HRT within five years is safe. So I would take some information from you and we will discuss about the risk factors and if you are a good candidates we can make a decision to prescribe it or not. Dr: What makes you interested in HRT? Patient: because of hot flushes. At this stage if the patient give you the symptom, it is your chief complaint. But if patient doesn't give you any symptoms, you should start with her LMP If she starts with the symptom of hot flushes, ask the patient 1.When did hot flushes start, 2.Is it all the time, 3.On & off or continues, 4.How many attacks, 5.Day or night, 6.How do you feel that you have it. 7.Night episodes, you have any night sweating, does it wake you up. Asked patient if the hot flushes wake her up during the night, and if she needs to change her gown of nights sweats. 1.Affect your sleep and how does it affect your concentration. 2.Change in your mood, anybody has told you that your short tempered, and if you 3. feel tired. 4. Some women with the same symptoms may notice some change in their sexual life. d)So the doctor should ask with whom do you live? e)Are you sexually active? f)Any dryness or pain during the intercourse? 8.Any change in your urination? Have you ever lost control? 9.Last period? •Are you periods regular or not? •If it's irregular, when did it start to become irregular? •Are your periods heavy or not? •Any clots? •*Any bleeding or spotting between periods? This is a very important point. 10.Bone pain? Any fractures? Any family history of osteoporosis? If yes, tell the patient that you will discuss this in another meeting. Because that's another session to discuss about using steroids, smoking, alcohol, caffeine, warfarin and diet. If she takes calcium supplements. MGOS for GYN cases: Menstural, Gynecologic diseases, Obstetrics, Sextually transmitted disease Dr: any history of gynecological disease like polyps, cysts, any pelvic intervention/instrumentation, surgeries. Dr: did you use to take any oral contraception? If yes, which one and did you have any side effects? Also you should ask about her last smear. Because she is 50+ you should ask about her mammogram. At any age you ask about Pap smear, once you reach 50 to ask about mammogram and when the patient pass 65 you should add bone density. You can ask about her obstetrics history, like have you ever been pregnant if yes how many times you have been pregnant? Now use the transition... Because this is the first time I met you, I would like to ask you about your past medical and social history. Is there any long-term disease, hospitalization before, any surgery, diabetes, or hypertension. Any history of allergy, and the medication she takes. ABCD: Active liver disease, vaginal Bleeding, Cancer, DVT For A you ask about any history of Active liver disease. Have you ever been yellowish? Any dark urine or pay stool? For B you should ask about any vaginal Bleeding? ... You have already asked these question before For C you should check about Cancer. I would like to ask about constitutional symptoms here to see if there is any endometrial cancer. Fever, chills, weight loss, appetite, lumps & bumps. A history of cancer in yourself or family (breast cancer, endometrial cancer,and colon cancer). For D you should ask about any history of swelling in the legs (DVT), any history of heart attacks, pulmonary embolism or stroke. Social history: smoking, taking alcohol, recreational drugs, how does she support financially herself, how does this affect her life and ask about osteoporosis.

Usually in this set of scenario, you tell her on the basis of the history you are good candidates for HRT. However as I told you it is an important information to tell you to make your decision. As we go through different stages of life usually for ladies, we go to the stage called menopause which is vary between person to person. At this stage there is hormonal changes and ovaries start to produce less hormones specialty estrogen and progesterone and that changes affect the whole body. It can explain about dryness, decreasing or absence of periods. And that's why we try to replace those decreased hormones by HRT. They are the same hormones but we give it through external sources either tablets or skin patches. As I told you before there is a balance it's your decision to make. And the balance is to use it up to five years. Using more than five years would increase the risk of stroke, heart attack or some cancers depending on what we call it estrogen dependent that includes breast and endometrial cancer. And some studies showed that it might increase the risk of Alzheimer's disease. So the risk of use for less than five years is not significant and still acceptable. So if you want to use it the shorter the better. To get rid off the hot flushes there are other measures like exercise or herbal supplements that you can try to improve the symptoms.

The HRTs are the same as OCP's but in smaller doses and you can take one tablet a day. They have a few side effects like weight gain, bloating, nausea, abdominal distention and pain but they improve by time. The serious side effects are headaches, swelling of the legs or chest tightness which whenever happen you should go to emergency room. By using these HRT's your periods may stop or you may see spottings. If the patient had hysterectomy before you only give estrogen without progesterone, otherwise you should give both. Because you take it regular shootout regular ultrasound scans to check the thickness of the endometrium and sometimes we should take a sample

INFERTILITY



(Sometimes it is not easy/Sometimes it takes time/I’m glad you’re here) Intro: As I understand you’re here because you’ve been to get pregnant for the last 14 mo, during the next few minutes tell me more about this difficulty. Did you seek medical attention before? (<35 –1yr/35 -40 6m0/>40 ASAP) PID & other med condts: ASAP How long have you been in this Relationship? How long have you tried? Have you ever been pregnant before? Have you ever had Mc or Abortion? Spouse: has he had children from a previous relationship? Let us talk about your Partner: (If less time Fast otherwise get details) Fast: Was he ever investigated? Did he have Semen analysis? What was his sperm count? Detailed: How is his health Does he have (Htn?DM/On meds) Any back trauma,back pain? Any Surgeries Any H/o mumps in childhood? H/O Ca, Rxt Cxt,STIs? Any Psy meds,Stress,travel a lot? Exposed to heat at work or recreational way? COITAL Hx Some qns about intimacy: How often do you have IC with husband? How do you monitor your temp? How do you measure your urine test? Is your husband capable of having an erection & ejaculation? Do you use any lubrication? MENSTURAL When was your LMP? GYN: SEXUAL: Any STIs Back to Content

16 YOF information about Pap Smear,



counselling, health maintaining issues (comes with HEADDSSS). Whenever there is counselling – take history. . Pap smear – What do you like to know about Pap smear? Usually we offer it for people who are sexually active, for that reason I’d like to know if you are in a relationship? Are you sexually active? When did you start? Any other relationships or partners prior? Do you use protection? What oprotection do you use? Any STD (blisters, ulcers, warts) in the last 6 mo? MGOS: M:LMP How often do you get your menses? Are they regular? Are your periods painful? Are they heavy? G – any gynaecologic disease? Any pelvic exam? O: Any H/o pregnancies/Abortions? Past medical Hx? HEADDSS .... Counsel about Seat belts Mood & Risks of suicide?

Counselling: Why? & How? I am glad you came here today to talk about Pap smear. As a matter of fact PS is one of the most successful screening tests to pick up one type of dangerous cancer called “Ca Cx” which is caused by a virus called Human Papilloma virus & a condom does not protect you from this. It is important to pick it up early, since by time it starts to give symptoms it is too late. Let me explain it to you. The area connecting the vagina to womb is called Cervix, & from the outside it looks like this:(Draw the circle with a dot) from this part we’ve to get a sample it gets infected with HPV virus which is similar to wart virus, but in the cervix, it leads to cancer. It should be done a week after your menses. It has to be done in a certain way, there will be a nurse with me,& you will be on your back, the exam bed has pedals to support your feet. We will use a speculum which come in different sizes & are plastic & disposable & we use a water based lubricant. If spatula rotate it to 360 & put on a slide, fix it & send to lab. If brush, rotate it 5 times put in fluid & send to lab. Results will be back in 2 weeks. If all is well, we will not contact you. PS has to be done every year .Once results are normal for 3 yrs & you’re with same partner you casn do it every 2 years till 69 years old, when you can stop ,If you change your partner, you’ve to do it yearly again. Other hazards – drinking and driving.



YOUNG WOMAN: ANTENATAL COUNSELLING



History Ask how Pt feels about being pregnant When did you do the test? How did you find out? Congratulate if she is happy. It is a very exciting time of your life. Ask questions about the pregnancy LMP: LLMP was it similar to prev menses or less bleeding? Calculate EDD; - 3mo + 7 days Sx:, N/V/Breast engorgement/Inc visits to washroom Rh status If nausea severe, ask about dizziness O: GTPAL Any complications in previous pregnancies: HTN/DM/Twins/Congenital anomalies G: (surgeries, infections, PAP’s) S: Any STIs PMH: Vaccinations, diabetes, hypertension, heartdisease, genetic diseases, kidney diseases, immunological diseases Past history of surgery-especially childhood Family Hx: Genetic disease, prematurity, early onset deafness SHx:Medications, Smoking, Alcohol, Recreational drugs OTC if on Aspirin ask to stop & change to Tylenol Social Hx: partner, support, provisions for child With whom do you live? How does your partner feel about this pregnancy? Do you feel safe in this relationship? Do you have pets? If has cat,not to change litter.

COUNSELLING:

I will confirm pregnancy by blood work Physical Investigations Vitals, weight, full exam including PAP smear (if not done in last 6 mo)and cultures CBC, Lytes, INR/PTT, Urea, Creatinine, Blood Type, VDRL, Rubella antibody, Serum folate, Hepatitis, +/- HIV, Urine dip and microscopy, ECG if indicated, +/- sickle cell and thalessemia screens. Nuchal Translucency at 12 weeks Maternal serum screen at 16 weeks Anatomy ultrasound at 18-20 weeks Glucose challenge test at 24 weeks +/- Rhogam at 28 weeks Diet, smoking, alcohol, exercise, medications, morning sickness Average weight gain is 25-35 lbs with 5-10ibs up to 20 weeks and then 1lb/week thereafter Risks of Down’s 1/200 at 35 Consult MD prior to meds For morning sickness eat bland foods, small portions, Diclectin is an option Hemorrhoids, back pain, heartburn and increased vaginal discharge are common Visits are every 4 weeks until 28 weeks then every 2 weeks Back to Content 19/2/2011 Introduction What to write on the note before entering the room: •Name •Age •CC •What required •DDx

First buzz – turn and read the stem (2m) Second buzz – knock the door and enter. The examiner might tell you that at the end he will ask you 1 or 2 questions. In the next buzz – it will be the time for the questions. If he doesn’t ask – complete the task. After another minute there will be a longer bip sound.

Short station (history, physical exam, s/e of psychiatric medications): 1.5 m buzz – enter Short buzz after 4.5 m (do “Thank you for the information, I’ll do the physical exam and I’ll take it from there.”

CC “As I understand you have ...for ... can you tell me more from the moment you started to notice it.” “I am glad you took the time to come here

In case of physical exam: Intro: name, position, why you are here, time that I am going to spend with you and for which purpose. “Good morning, my name is...I am the attending physician here. I understand you are here because....In the following 5 minutes I will perform physical exam, hopefully towards the end we will reach a workable plan. If you feel any discomfort please inform me. Do you have any questions?”

Imaging, blood work “Hello, good afternoon Mr. ... as I understand you are here to get your blood work results, since this is the first time I see you before I am discussing the results with you I have some questions to discuss with you.” Than: Why, 1st time, who and when. In case of breaking bad news: SPIKE Setting Perception (What is your understanding about the test, and why you are doing that” Invitation (How much details do you like to discuss with you? DO you like anyone to be with you?) Knowledge (What do you know about the condition?) Expectations (What are your expectations from today’s visit? What is your expectation from the result?) Gives the result.

Questions for telephone session: What’s your number? Where do you live? “...did I say it right?” Connecting with a colleague:

Psychiatry

Psychosis

1.55 yo, believe that have strange feeling in hands. Do mental exam. Either organic, late onset of schizophrenia, not complying with medication. 2.35 yo, believes that the RCMP chasing him. Persecutory delusions. Reassurance about his safety. DDx substance abuse. 3.24 yo, brought by his roommate because haven’t been himself in the last 10days. Can be acute psychosis, substance abuse, HIV, mania 4.30 yo, wants to arrange DNA test for his children. 5.17 yom, worried about contamination – wants to be admitted to get rid from it. 10min – councsel. 6.22yo, diagnosed with schizophrenia 6wk ago, concerned about his condition. Think about suicide! 7.17 yo male, pain in his neck. s/e of drugs. 8.35 yo, brought by the police because he wanted to slaughter his children (thinks he his Abraham). Ask him “Who is Abraham?” Ask early about: “How is your mood today?” – To differentiate from mania.

Mood (Presenting symtoms) MI PASS ECG 1.Low mood for the last 6w. 2.Patient with difficulty to sleep: 2.1.22 yof 2.2.35 yof 2.3.75 yof asking for sleeping pills 3.Suicide case. 4.Presentation with tiredness 34 yo. 5.40 yom hasn’t been himself for the last 3w – his wife concerned. 6.70 yo has back pain for 3w (x2 cases). 7.Dysthemia case. A young lady with low mood for years

DIG FAST 1.Impulsive behaviour – might be presented with intoxication to the ER. Sexual activity with no protection. Issues with the law (fighting in the bar, waking up the neighbours). 2.Grandiosity – some delusional ideas. 3.Patient who wants to discontinue the medication.

Anxiety 1.Panic attack – heart racing, sob, dizziness, tingling, numbness (hyperventilation – hypocapnea) STUDENTS FEAR 3C’s 2.Patient already diagnosed recently with PA or Panic disorder or generalized anxiety – discuss the treatment. Delirium and Dementia – Cognition disorders 1.57 yom difficulty with her memory. History and mental status exam (mini mental). 5min. 2.67 yof difficulty with her memory. Score for mini-mental 20. 3.67 yom came with his wife, concerned about his memory for the last 3m. Next 15min talk with him. 4.70 yom, s/p hip replacement 3d ago. Didn’t sleep last night (reversed sleep cycle) – delirium. Fragmented sleep cycle – dementia. 5.His dad is not being himself. You talk with the son. You cannot do mini-mental to the son. 6.Talk to the son about his mom that is in senior home. He is concerned – she was given 15u instead of 5u of Insulin. “It looks like there is some kind of medical error.”

Eating disorder, borderline, schizotypal, conversion



1.16yof, the parents concern that she loses weight. Part of the DDx is figure out that she has amenorrhea.

2.22 yof wants to be admitted. She wants to kill herself. If is the first time – you need to admit her. If it is several times – it’s not necessary to admit her. You have to finish the assessment. If she lives the room before finish the interview – you will write form #1. Usually people with psychiatry problem have: social worker and case manager. Have you ever seen by psychiatry. 3.Schizotypal disorder 4.Sudden loss of function. Seen by two doctors, one of them specialist in that field – it means it is conversion. 4.1.Loss of vision in her rt eye. Seen by ophthalm. 4.2.22 abdominal pain for 3w, seen by a surgeon a week ago. Counsel. 4.3.Headache for the last 6 mo, she wants to renew her thylanol 3 (x2) 5.Alcholism 5.1.AST>ALT, GGT elevated 5.2.His wife concerned he is not himself for the last 3m 6. Suicide (SAD PERSONS – score more than 4 you have to admit). 6.1. Overdose of aspirin. Medically clear.

Psychiatry Assesment



In PSY Ds look for: I.TIME II.CRITERIA If CC is psychiatric, make an early decision in MOAPS format, where: M=Mood Depression --MI PASS ECG •Mood How is your mood? Do you feel down? Do you cry a lot? Have you felt that before? “You look down for me – is there any chance you are depressed?” Is your mood always down or does it alternate? Have you been very happy at times? if YES: enquire about Mania

•INTEREST: Have you lost interest in activities in doing activities that were enjoyable to you? “Anything makes you happy?” If he doesn’t it any more – “Why?” (Doesn’t have time, no energy, or doesn’t enjoy it) •PSYCHOMOTOR RETARDATION/AGITATION: “DO you feel things are getting slower? Do you need more time to do things you did before?” •APPETITE “Did you lose weight deliberately?” •SUICIDAL Ideation “Any plan?” “Did you live a note?” “Did you start to give your belongings to others?” •SLEEP “When you go to sleep? When wake up? Do you feel fresh?” •ENERGY “Do you feel tired?” •CONCENTRATION “When you read an article can you finish it to the end?”

“Do you find to focus to concentrate in one subject?” •GUILTY “Do you feel guilty?” “Do you feel there is no hope in life?” After getting two depression episodes. If they are at least two month apart – Major depressive For teen age istead of mood and interest is replaced by irritability and droped in school performance. In elder person you might have need somatic disorders. Bipolar I (Mania) - DIG FAST (elevated mood + at least three out of the seven for a week) sometimes it is irritated mood – than you need 4 out of seven for a week. Usually they don’t last a week – so if they end up in hospital look for the criteria even for less than a week. •DISTRACTATIBILITY: “DO you find difficult to focus on one subject?” “Are you working on more than one project at the same time?” “How many projects do you work in?” – “Are you able to finish it or not?” •IMPULSIVITY “Are you spending more time than before?” “Are you borrowing money from other people?” “For what reason?” “Are you drinking more than before? Do you use cocaine? Which happen first? – elevation of mood or using cocaine?” “With whom do you live? Are you sexually active? How many partners do you have? Do you practice safe sex?” “Do you have any problems with the law? Speeding tickets? Any fights? •GRANDIOSITY: “Do you believe you’re a special person?” “Do you believe you deserve to be treated in a special manner?” “Do you feel you’ve a special power?” “Do you feel you’ve a special mission?--- if Yes Always ask what is the mission? & probe deeper & inquire about Delusions* • FLIGHT OF IDEAS: Do you feel thoughts racing in your head? Do people say you’re jumping from topic to topic • GOAL DIRECTED ACTIVITY: “How much time you spend in your activity?” •SLEEP •TALKATIVE “Anybody mentioned that you are talking faster or more than others?” Ask:If first episode or has it occurred before? Also look for OPPOSITE mood Relapse rate for the first time: 60% next time it is 80% third time 95%. Intro Why? Concern Assess mood today How you were diagnose with bipolar I? When? Why? Were there any serious consequences? Regular follow up? When you saw last your doctor? What was the level of Lithium that time? How do you feel about Lithium? Did you notice any s/e? Have you ever forget to take the drug? (It will be easier in the counselling). “I know that you have been this question before but I am going to ask you again – do you hear any voices. Do you worry a lot...” Counselling Compare mania to depression. What is your understanding of mania. It is a condition...

O=ORGANIC (I MAD): •ENDOGENOUS (ILLNESS); Depression: Hypothyroid/Lupus/Ca Pancreas/Post MI/CVA •EXOGENOUS: (Substances: MAD) M: Medications: Dosages/duration/SE/Toxicity A: Alcohol: How much/day? D: Drugs: 1.What drugs have you tried? 2.When 3.How much 4.Any Hx of O/D,W/d,SE,hospitalizations? 5.Which drugs NOW?

A=ANXIETY SCREEN: Do you worry a lot? Interview Questions to Establish Specific Anxiety Diagnosis Questions Further Inquiry 1.Do you have sudden episodes of intense anxiety? Establish nature of attack * 2.Do you have difficulty going to places to Inquire about crowded places, line-ups, which you used to be able to go? movies, highways, distance from home. 3.Do you have difficulty talking to people Establish situations (one-on-one or groups). in authority or speaking in public? 4.Are you afraid of blood, small animals or Establish precise feared situation. heights? 5.Do you repeat actions that you feel are Ask about washing, counting, checking and excessive? hoarding. 6.Do you have thoughts that keep going in Ask nature of thoughts (illness, harm, sex) your mind that you can't stop? Relieved by washing hands/praying. Do these thought cause stress for you? How do you relieve this stress? 7.Have you experienced any emotionally Establish the nature (accident, sexual, stressful events? torture) and timing of the trauma. When & What happened? 8.Do you worry a lot of the time? Ask about worries related to health, family, job and finances.

P=PSYCHOSIS HALLUCINATIONS: VISUAL HALLUCINATIONS: 1.Do you sense things that are not actually there? 2.Do you see things that others do not see? 3.What do you see? 4.Can you describe what you see? 5.Does it have a message for you? 6.Does the message ask you to harm yourself? 7.How do you feel about it? 8.Is this the first time? AUDITORY HALLUCINATIONS: 1. Do you hear voices other people cannot hear? OR : a)If you’re alone & nobody with you, do you hear voices? b)Do you hear voices inside your head? 2.How many voices? 3.Are the voices familiar? 4.Do you recognize the voices? 5.Do they talk to you? 6.Do they talk about you? 7.What are they asking you to do? 8.Do they ask you to harm yourself? 9.Do they ask you to harm anybody else? If YES: 10.What is preventing you from doing this?........Screens for INSIGHT

11.How do you feel about these voices? (“Some people feel comforted when they hear these voices, others feel threatened”). DELUSIONS:

1.Do you feel anyone wants to hurt you or harm you? If YES: WHO & WHY? 2.Anybody tries to control you? 3.Anybody wants to put thoughts into your head? (Thought Insertion) • Anybody wants to steal thoughts from your head? (Thought withdrawl) 4.Others can read your thoughts? (Thought broadcasting) 5.When you’re watching TV or reading the News, do you feel they’re talking about you? (Ideas of reference) 6.Do you feel any part of your body is rotting? 7.Do you feel everybody is falling in love with you? S=SELF CARE •HOMICIDE: •SUICIDE •SOCIAL HISTORY: oWith whom do you live? oHow do you care for yourself?

PAST PSY HISTORY: 1.Any similar Sx/Ds in past? 2.Any Other psy Sx/ Ds in past? If YES: 3.Analyse Sx/extent of incapacity/Rx recvd/names of hosp/Compliance PAST MEDICAL HISTORY: R/OAny medical illness:DM/HTN/Thyoriod/Surgery/Head trauma/HIV/AIDS/Syphillis SAD – Smoking, Alcohol. Drugs (especially long use of cocaine) Screen for anxiety – are you fear a lot? any fears, especially from open places? Screen for psychosis – “anybody wants to harm you? Sometimes people having similar experience – they might hear voices or see things other people don’t see. How about you?” FHx: •Anyone in family with similar Sx/Ds •Anyone in family with other pSy Sx/Ds •Drinking / hospitalized from psychiatry reason? •Relationships SADD FHx: •Suicide •Alcohol •Depression/Divorce/Drug PERSONAL Hx: 1.Prea-dulthood 2.Adulthood: Social activity: Support system, Friendships (depth/duration/Quality) isolated, asocial With whom do you live? If he lives alone – do you have any friends you talk with? Current Living Situation: Where/with whom/Relationships at home/financial support/Assistance OCCUPATIONAL HX: How do you support yourself? What are your ambitions/goals/relationships/Conflicts at work?/STRESSES/ Job changes MARITAL & RELATIONSHIP Hx; Age/Duration/areas of (dis) agreements,outcomes MILITARY Hx Gen Adjustement,combat,Injury Educational Hx: Highest grade/Area of interest Religion:Strict/Permissive attitude towards suicide

PSYSOCIAL Hx: Sx/attitudes/orientation/practises/STDs (HIV) 1.Are you currently in a relationship? 2.Are you sexually active? 3.Are you active with males, females or both? 4.How long have you been in the current relationship? 5.Are you practising safe sex? 6.Are you using condoms all the times or just sometimes? 7.Is there a risk for you to be at a risk for STDs like HIV/HBV/Syphilis? 8.How about your partner? 9.How about your previous partners? Or the previous partners of your partner? 10. Have you or your partner tested for HIV,HBV or Syphilis?/When/Outcome 11.Are you currently seeing anyone else? 12.What other relationship have you had in the past?/ Anytime with more than one person at a time 13.Have you ever paid/received money for Sex? Allergies

MSE/MMSE

APPEARANCE: 1.Well dressed 2.Well groomed 3.Dress matches weather 4.Given age matches chronological age BEHAVIOUR: 1.Agitated 2.Psychomotor retardation 3.Eye Contact 4.Co operative 5.Non hostile 6.No abnormal movts/Jerking/lip smacking C/SPEECH:

1.Volume 2.Tone 3.Fluency 4.Articulate MOOD& AFFECT: Mood;Subjective Sx in pts own words Affect (qarms) 1.Quality: Euthymic/depressed/elevated/Anxious 2.Appropiateness to thought content 3.Range:Full/Restricted/Flat/Blunted 4.Mood Congruence 5.Stability: Fixedt/Labile PERCEPTION: Hallucination Illusion THOUGHT PROCESS: Coherence/Incoherent Logical/Illogical Circumstantiality/Tangentiality THOUGHT CONTENT: • Suicidal/Homicidal Ideation 1.Low-- fleeting thoughts,no formulated plan,no Intent 2.Intermediate--More frequent ideation,well formulated plan,No active intent 3.High --Persistent ideation & profound hopelessness/Anger,well formulated plan,active intent,believes suicide,homicide is only helpful option available • Obsession: 1.Recurrent or persistent thoughts,impulses or images that cannot be stopped which is intrusive or inappropriate 2.Cannot be stopped by reason & Causes marked anxiety & distress • Preoccuption: •Overvalued Ideas: •Ideas of reference: •Delusions: •Magical thinking: •First Rank Sx of Shz:Thought insertion/T withdrawal/T broadcasting COGNITION: MMSE Level of consciousness Orientation in time/place/person Memory: immediate,remote,recent Attention & Conc Global evaluation of intellect: Intellectual Fns: INSIGHT: JUDGEMENT:

DELERIUM MMSE



1st reassuare the pt,calm him down talk & do MMSE O-O-O-O-O = 5 = Time: Year/Season/Month/Day/Date O-O-O-O-O = 5 = Place:Country/Province/City/Street/No O-O-O = Immediate recall:Black/Honesty/Tulip (if he makes mistakes,correct him but give _ve O-O-O-O-O = Concentration: Can you spell WORLD backwords? O-O-O = Delayed recall O-O-O = Comprehension: 3 step command O-O = Naming 2 objects (pencil & paper) O = Reading ; write a sentence: Close your eyes & ask him to follow the command O= Writing O = Repeating; No ifs ands or buts O= Copying

Why Delerium: Fever Ha/photophobia? Did you eat last night? Abdominal pain /Flank pain? Calf pain? Medications Alcohol (Last time & now) CSx: Ask examiner for I/O chart & medication chart

FORMS to Be filled:



If during an interview a pt decides to leave & not finished...... If pt wants to kill someone or himself....ADMIT If Pt refuses to be admitted & insists on leaving: INVOLUNTARY ADMISSION----------FORM 1 And another doctor must come & asses him. Cannot hold in hospital for > 72 hrs

If a wife /partner brings & dr assesses & there may be a chance that the Pt may commit suicide/homicide, pt can be sent home, on condition that if Pt detoriates she should call back & immediately & bring Can file FORM1

If pt refuses voluntary admission with first dr,but second D. Can assess & can discharge if he feels fit for discharge,or admit on VOLUNTARY basis Admission always better on voluntary basis

If second dr admits on involuntary basis it is FORM 3 & valid for 2 wks During these 2 wks,pt improves,& so can be discharged, or gets voluntary admission When admission voluntary --- FORM 4 Form 4 is renewed Released on --FORM 5 Thus FORMS 3 & $ are for Rx

PANIC Attack



ONSET: 1.When did it start 2.How did it start? 3.What were you doing at that time? COURSE:

1.Is the Intensity same now as it was when it all started? 2.How about the frequency? 3.What made you come in today? DURATION: How long does each attack last? PQRSTUV

1.Where exactly does it hurt you? 2.Can you describe the pain? 3.Does it move to anywhere else n your body? 4.On a scale of 1 to 10,wher 1 is mild & 10 is max,where would you rate this pain? 5.Has this affected your life in any way? 6.Is there a particular time it comes on? 7.Did you ever have this before? AAA

Alleviating Fcts: What makes it better? What Aggravates it? 1.Exercise 2.Stress 3.Certain situations or places? 4.Coffee? 5.Medications?

6.When passing urine or having a bowel movt or cough? ARE YOU AFRAID THAT AN ATTACK IS COMING? Assoc Sx: first R/o cardiac then GI & then shift to Psy •N/V/Diarrhoea •Heart racing/ Sweating/ Dizzy •Decreased wt & Increased appetite/ Tremors •Headache •Tingling & Numbness •Nervous & Out of control •Do you feel you’re going to die? •During these attacks do you feel things are unreal? •During these attacks do you feel you can see yourself? •Do you feel you’re going crazy? •Do you feel worried about being in places or situations where escape might not be possible e.g: Crowded places Closed spaces If YES: *What place or situation? *What happens in such a situation?

*How has it impacted your life? *How have you dealt with this issue? Here ask for anxiety disorder: Are you a person who worries a lot? Interview Questions to Establish Specific Anxiety Diagnosis Questions Further Inquiry 1.Do you have sudden episodes of intense Establish nature of attack anxiety? 2.Do you have difficulty going to places to Inquire about crowded places, line-ups, which you used to be able to go? movies, highways, distance from home.

3.Do you have difficulty talking to people in Establish situations (one-on-one or authority or speaking in public? groups). 4.Are you afraid of blood, small animals or Establish precise feared situation. heights? 5.Do you repeat actions that you feel are Ask about washing, counting, checking and excessive? hoarding.

6.Do you have thoughts that keep going in Ask nature of thoughts (illness, harm, sex). your mind that you can't stop? 7.Have you experienced any emotionally Establish the nature (accident, sexual, stressful events? torture) and timing of the trauma. 8.Do you worry a lot of the time? Ask about worries related to health, family, job and finances.

a. MOAPPS

MOOD RISK FCTS: To gain more insight into your condition, I need to ask some questions about your personal life : Do you:

•Smoke •Take alcohol •Recreational drugs (in case of cocaine – ask if sniffs or injects it. If injects – continue by r/o HIV symptoms) •Are you on any medications? •Did you take anything for a cold or flu • Are you taking OTC products/herbal remedies? •Are you allergic to anything? •When was your last period?

Are you going through a stressful situation in your life? How are you coping with it? FAMILY H: Does anyone in your family have a similar condt? SOCIAL H: COUNSELLING: From what you’ve told me, your chest pain seems related to a condition called “Panic Attack” It is a fairly common condt It's not known what causes panic attacks or panic disorder. Things that may play a role include: • Genetics •Stress

•Certain changes in the way parts of your brain function Some research suggests that your body's natural fight-or-flight response to danger is involved in panic attacks. For example, if a grizzly bear came after you, your body would react instinctively. Your heart rate and breathing would speed up as your body prepared itself for a life-threatening situation. Many of the same reactions occur in a panic attack. But it's not known why a panic attack occurs when there's no obvious danger present Nonpharmacologic Choices •Caffeine or other stimulant use should be reduced and controlled. •Alcohol use should be minimal; it should not be used to control anxiety. •Reduce the “as-needed” use of short-acting benzodiazepines as much as possible; ideally, such use should not be continued for longer than 4 days. •Stress reduction, including relaxation training and time management, is often helpful initially. • Specific cognitive behavioural therapy (CBT) may be required;

he selective serotonin reuptake inhibitors (SSRIs) citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline are all effective in reducing panic SSRIs and SNRIs have become first-choice agents in treating panic disorder with or without agoraphobia.2There is usually a delay in response to these agents that may be accompanied by initial agitation. Combining the SSRI or SNRI with a brief course of low-dose benzodiazepine augmentation therapy (i.e., no longer than 8 weeks) can increase adherence to medication and produce a more rapid response than with antidepressants alo

Panic Disorder with Agoraphobia

The pharmacologic treatment of panic disorder with agoraphobia is the same as for panic disorder. However, much of the disability in panic disorder with agoraphobia arises from the avoidance behaviour rather than the panic attacks. This can be addressed with cognitive behavioural therapy (CBT), even if medication reduces or eliminates panic attacks. CBT can be more effective alone than when it is combined with medication.8 However, access to specialized CBT is often limited.

Personality Disorders



“Am I crazy?” “There is no medical condition called like that, however sometimes patient have some difficulties with their thoughts and reality, it is called schizophrenia.” Mental Status Exam: Appearance wise...dressed, gromed Behavioral wise: Speach wise: Mood wise: Perception: Thought processing: Thought content: Judgement:

Mini-Mental: delirium, dementia, post-concussion



Writing a chart (SOAP):

Subjective Objective Assessment Plan

Borderline Personality

Work on this event and previous attempts.

If she was diagnosed – “have you ever seen by psychiatrist? What was the diagnosis? What you didn’t contacted your case manager/psychiatrist? ER or ICU or Weapons? In Toronto – contact with the case manager/psychiatrist. What is the trigger that makes her come today? In case of crisis – do you have anybody to contact? Refer to crisis team/Social worker/ “In order to determine if I can admit you or not I need more information... Always the same pressure like today? If the patient mentions work – “what do you do for work?”

Anything happen recently? Have you had any other relations? Is it difficult for you to maintain relation? Mood, Anxiety, Drugs/Alcohol/

22 yo wants to be admitted.

Borderline personality

When Pt wants to be admitted she may say,if you do not admit her,something bad may happen like last time. Pick up early when she says this ...... Start with EVENT: Check previous attempts at suicide Pick up early when she says something bad happened Ask: WHAT happened? If Suicide attempt....... 1.When & How many times before

2.Was she seen by psychiatrist? 3.Has she been to ER before? 4. Was she diagnosed & Rxed 5.Why can;t she contact her psychiatrist? 6.Was she admitted in ICU? 7.Which Rx programme does she have? 8.Does she have a crisis team & case manager? 9.Why didn’t she contact them? If repeated attempts at suicide: Which treatment programme does she have? Is admission one of it? CRITERIA FOR BPD: •Fluctuating mood either very happy or sad •Splitting

•Feeling of emptiness •Failure in maintaining a relationship both on social & employment areas •Impulsivity Drugs & Sex •Was sexually abused as a child Let her go or admit 1st episode admit needs Psy assessment Look for TRIGGERS that made her come in today Do not let her manipulate you I really like to help you,I’m on Er duty My job is to asses you & admit you Once admitted another Dr will asses you

•Can you tell me why you want to be admitted? •I really want to help you... •What bad thing will happen?

In order to admit you or not, I need more info & therefore I need to ask you, & admitting you is one option

If pt says Something Bad will happen o What do you mean? o When did it start? o Did it happen before? o How many times before?

NO EMPATHY

When did it happen the 1st time? When was the last time? What was done? Were you admitted to ICU? In addition to slashing your wrists have you used any other methods?...Like weapons or medications?

Pt says she feels some pressure Ask if the pressure felt today is the same as the pressure felt last time I want to help you looks like the last few days were stressful Have you been seen by Psy? What was the diagnosis? Do you still see the Psy?

When was the last time you saw him/Her? Why did you stop? What medication were/are you taking? In addition to psy is there a case manager? In case of crisis do you have anybody to talk to/ or contact? What prevented you from talking to them today?

Ask prior to Event?

What happened 6 wks ago? How did you lose your job?

What sort of job were you doing? What happened? Prior to that what sort of job were you doing? Is it difficult for you to stay in one job? Have you tried to find another job? Anything happened last night? If Boy friend left her.....How long have you been together? How does she feel about it? Was he supportive? At what age was she sexually active? Does she find it difficult to stay in a relationship? MOOD

DEPRESSED: Ask for HOMICIDAL ideation Manic Ask Drugs/Spending/Impulsivity ANXIETY After boyfriend ask about fly support...... Back to Content  

Depression



Sleep

If comes Tired  Sleep  Energy  Mood Sleep – how does it affect you? DO you feel tired? •―During the past month have you often been bothered by feeling down, depressed or hopeless?‖ •―During the past month have you often been bothered by little interest or pleasure in doing things?‖

MI PASS ECG

(TO diagnose depression – needs 5 out of the 9, in which one them should be either M or I. In teenagers irritability can replace either M or I, in elderly it can come with a somatic presentation) If it is one episode it is called: Major Depressive Episode (need 2w in which most of the days with depressed mood, and 4 more criteria). If there are 2 or more MDE within the same 2m – it is Major Depressive Disorder, if it is more than 2m – it is Recurrent Major Depressive Episodes.

M

How do you feel recently? How is your mood? Any chance you are depressed?

I

What do you enjoy doing? Are you still enjoy hobies? Anything brings happiness to you? Why don’t you enjoy any more? No time? No energy?

P

Do you think things are getting slower? Do you think you need more time to do things you used to do before?

A

Any change in appetite? Did you lose weight? How much weight did you lose? Was it intentional or not?

S

How about sleep? How many hours do you sleep? When do you go to bed? How long before you fall asleep? DO you wake up at night? Why do you wake up at night? DO you feel refreshed at the morning?



S

Do you feel any chance that you might harm yourself, end your life, or any ones? If patient says I wish I am dead, consider either he has only a feeling or a plan (active) Do you have a plan? What is preventing you? Did you leave a note? Did you start giving your belongings to others? (These are definite questions for a plan)

E

DO you feel tired? C Do you find it difficult to focus on a specific task (for example if you are watching TV – you can stick to the same program all through? Can you finish an article?)

G DO you feel there is no hope in your life? Do you feel guilty?

Regardless of any specific psychotherapy, measures to enhance treatment compliance are useful; e.g., providing psychoeducation with the following 5 simple messages is effective:19 •Take medication daily

•Call this number for questions about side effects or other issues •Remember that it might take 2–4 weeks to see a noticeable effect from antidepressants •Continue to take medication even if you are feeling better •Do not stop taking the antidepressant without checking with the physician

42 yom hasn’t been himself, his wife arranged for the meeting.



INTRO: As I understand you’re here today,as your wife has some concerns about you. Can you tell me more about it?

Give confidentiality. Counseling (last 2-3m): Based on what you told me your symptoms are consistent with a condition called “depression.” We believe it is caused because of imbalance in some of the chemicals in the brain. Sometime there is an event in life or cause that triggers that situation. It is common and treatable. We need to r/o other causes – and for that we need to do some blood work. What did I do wrong to feel so depressed? Depression does not occur because someone has done something "wrong". Like any other medical illness, depression is caused at least in part by biochemical changes in the brain, which lead to depressive symptoms. This is why medications which help correct chemical imbalances in the brain relieve depression. In fact, if a chemical imbalance is not present, antidepressant medications will not have any effect - they will not make a person "happy" when they are not clinically depressed.

How long before I feel better? Generally speaking, people will start to notice improvement in symptoms such as sleep disturbances or crying spells and energy levels a few weeks after starting their treatment. Improvement in depressed mood is usually slower, and it may take six to eight weeks before people notice they are feeling much less depressed. If someone has not improved after three to four weeks of therapy, the dose of the initial medication may be optimized, a different drug may be added, or the initial drug may be substituted. Up to 80% of people with depression do get better with the right medication. Will my depression come back?

The likelihood of depression recurring depends on how many previous episodes you have had. For people who are experiencing their first depression, the likelihood of having a second episode is around 50%. For people who've had two depressive episodes, chances of having a third are around 70% and for Those who've had three and more episodes, all but 10% will experience further illness.

Having someone else in your family who has depression makes it more likely your own depression will recur. Other risk factors for recurrent depression are the presence of chronic medical problems, a history of early trauma or abuse, dysthymia, onset of depression younger than 25 years or older than 60 years, and a long pattern of negative thinking, low self-esteem and relationship difficulties. A depression which does not completely resolve with treatment, as well as severe depression, also increase the likelihood depression will recur. This is why most people with depression need to be treated for at least six to nine months to prevent relapse, and for greater than 12 months if someone is being treated for a recurrent episode. Depending on the likelihood of depression recurring, some people stay on the same dose of their medication for long-term maintenance therapy. The saying doctors have is, "The dose that gets you well is the dose that keeps you well" and people will do better over the long run if the same dose is used throughout. Can I pass depression on to my children?

Certain types of depression, especially, bipolar affective disorder, would appear to run in families. However, even identical twins do not share an equal risk to develop depression, and depressive illness appears to be a combination of vulnerability to depression (part of which may be inherited but not necessarily), difficult life events and biochemical imbalances in the brain. I have trouble reaching orgasm now that I'm taking an SSRI. Can I stop my medication on weekends to improve my sexual function?

Some doctors recommend drug holidays where people stop taking their medication on the weekend. The biggest concern about stopping and starting medication revolves around compliance issues, but there is some evidence that people may not respond as well to the medication if treatment is continuously interrupted. For these reasons, drug holidays are not recommended and an alternative antidepressant or an additional medication to offset unwanted sexual side effects are better solutions. Regardless of any specific psychotherapy, measures to enhance treatment compliance are useful; e.g., providing psychoeducation with the following 5 simple messages is effective:19 •Take medication daily •Call this number for questions about side effects or other issues •Remember that it might take 2–4 weeks to see a noticeable effect from antidepressants •Continue to take medication even if you are feeling better •Do not stop taking the antidepressant without checking with the physician

There are good options to treat it. If you choose to go to talk therapy I can refer you to a psychology. On the other hand we can use medications which are generally safe. Called SSRI similar to Prozac, however like any other medical intervention have some side effects. Most of them are minor, usually improve with time – headache, sexual...however the improvement of your mood will lag behind your improvement in your energy, we call that the window gap, and this is of concern to us. All contracts are verbal, besides the drug contracts – “I promise I will not use ...again...”

Mania



DIG FAST For diagnosis we need elevated mood + 3 criteria of the above 7 for a whole week. Sometimes irritable – you need 4 criteria. D DO you find it difficult to focus on one subject? Are you working on more than one project on the same time? How many projects are you working on? Can you finish it on time?

I Are you spending more money than before? Are you borrowing money from others? Are you maxing out on your credit card? Do you drink alcohol? Are you drinking more than before? DO you smoke or take recreational drugs? (If taking recreational drugs – feeling high) If taking cocaine – what happened first: the episode or the taking the drug? With whom do you live? Are you sexually active? How many partners have you had recently? Have you used protection? DO you have any problems with law? Any speeding tickets? Any fights?

G

DO you feel you are special? Do you feel you deserve to be treated differently? DO you have special powers? Do you have special mission?

F

DO you have thoughts racing in your head? What kind of thoughts? A How much time do you spend in your activities? S Lack of sleep? T Did anyone tell you that you are talking faster than before? Manic

1 Manic episode = Bipolar I Ask if it is the first time or has it happened before. How about the opposite. Have you ever felt high? Greater than 7 days in a row? Insomnia in elder

Difficulty in sleeping for 6 months Can you tell me more about it since it started? Did you seek medical attention? OCD Anything at that time? From that time till now – every night? When do you go to bed? Whe do you fall asleep? When do you wake up?

Before you fall asleep what do you think? What comes to your mind? When you sleep – do you wake up? Any nightmares? If she says she has to wake up for breakfast ask why she has to wake up? How old is your son? Has he been always with you or is he left and come back? Can’t the prepare breakfast for himself? Anybody else at home? How about your husband? CSx PMHx SHx How does son support himself?

Is he under stress? What is the nature of your relationship? Give confidentiality? How do you support yourself financially? Any financial concern? Ask if son contributes to finances? If son consumes Alcohol? (How much? Does he loose control/shouts?) Does he get angry to swear to get physical? Does he get accesses to your finances?

Did you talk with anybody about it? Do you feel safe going back home? Does he have access to fire arms? DO you have suicidal or homicidal ideation? Based on what you told me – your sleeping troubles seems to be related to stresses in your life called ―Elder Abused‖ which is illegal and crime against law. It is nor your mistake and you should not accept that. You need to call the police. From studies it has shown that police interevention improves such situations.

Son needs help – can you convince him? Police will protect you and son will be sent to rehab and anger management. I’ll be giving you sleeping pills for three days and f/u within 3d.

  Marijuana Counselling



(Mother comes in to see you as she has discovered Marijuana in her son’s belongings) INTRO: As I understand you’re here because you’re concerned about your son.

What is his name?

What is your concern? How much did you find? Did you ask him about it? •WHAT MAKES YOU BELEIVE IT IS MJ ? Is he using it? Or Is he carrying it? Is it the first time you’ve found it?

•Did you notice any CHANGES in his behaviour? Is he excited? Laughing out of nowhere? Is he preoccupied?

Does he stare at a wall? Does he talk to himself? Is he aggressive? Any problems with the law? Any fights? Any criminal records? Is he more isolated?

•How is his MEMORY? Is he more forgetful/lose his stuff? Does he take more time to react? Does he spend more time in his room? How much time do you spend with him? How much time is he out of the home? How much time does he spend with his friends? Do you know any of his friends? What kind of activity are they involved in? •Does he have a lot of MONEY?

Does he ask for money? Do you believe he steals money? Do you think he smokes/or drinks alcohol? •How would you describe his MOOD? Is he depressed? Is he still interested in his hobbies? Does he worry a lot?

Does he have excessive fears & avoid situations? Do you have concerns that he may harm himself or anyone else? EDUCATION: How is he doing in school? Have his grades dropped? DIET: How is his general health? Have you ever seen a psychiatrist? Fhx: SAD COUNSELLING:

Based on what you’ve told me.There are no changes in his health & behaviour (assumed that there were no changes in behaviour as per mum) When it comes to Marijuana it is a commonly used drug by teenagers, sometimes only once for experiment. When we talk about Substance Abuse & drugs we talk about different categories.

Marijuana is a SOFT DRUG,others like: Coccaine,Heroin& Amphetmanies are HARD DRUGS Let us talk about Marijuana first. It is from the Cannabis family & affects the brain by feeling happy, excited & enhances experience.Sometimes with prolonged use or in high doses can cause side effects including apathy. It interferes with memory,& can interfere with his studies & function & fine motor skills & may not be able to operate machinery It impairs judgement & he might take risks. Can cause Lung cancer

In some teens,in high doses unmasks schizophrenia & cause psychosis Interferes with sexual function & can cause infertility & weight gain By itself marijuana is not strongly addictive & hence he can stop it at any time with help.One of the concerns of Marijuana though is it acts as a bridge to Hard drugs which are addictive i.e you’ve to increase the dose to have the same effect,which is called “TOLERANCE”,& then one cannot stop the drug as it causes withdrawal . It is a crime to use,hold hard drugs.People can lose their jobs. If injected increases risk of HIV,Hepa B & C PLAN If you like,bring your son here I can talk to him. It is better to be a confidante to him. Try to be close to him, someone he can trust & can talk to.Try to make sure who’re his friends,& make sure you know what he is doing.Keep him busy with activities. If there are any druh prevention programmes in your community or his school,get him to attend them & gets the knowledge.

In case of the resident who was asked to backup his supervisor orthopaed 4.I am competent – to emphasize 5.Short term – we don’t have time so we need to see her urgently 6. Long term – solve the situations that it wouldn’t occur again

INSOMNIA:



The Sleep History 1.Time data (can also be collected as part of a sleep diary – 1. Did you nap or lie down to rest today? If yes, when and for how long? 2.What time did you go to bed last night? 3.What time did you put out the lights? 4.How long did it take you to fall asleep? 5.How many times did you awaken last night? 6.How long was your longest awake period; when was it? What time did you finally awaken? 7.What time did you get out of bed? 8.How many hours sleep did you get last night?

2.Questions about the sleep period 1.Do physical symptoms, such as pain, prevent you from falling asleep? 2.Do mental or emotional symptoms (e.g., worry or anxiety) prevent you from falling asleep? 3.When you awaken during the night, what awakens you? (Snoring? Gasping for air? Dreams/nightmares? Noise?)

4.When you get up for the day, do you have any symptoms? (Headache? Confusion? Sleepiness?) 3.Questions for the patient's bed partner 1.Does your partner snore, gasp or make choking sounds during the night? 2.Does your partner stop breathing during the night? 3.Do your partner's legs twitch, jerk or kick during the night? 4.Has your partner's use of alcohol, nicotine, caffeine or other drugs changed recently? 5.Has your partner's mood or emotional state changed recently? 6.What do you think is the cause of your partner's sleep problem?

Hygiene Guidelines

1.Keep a regular sleep–wake schedule, 7 days per week. 2.Restrict the sleep period to the average sleep time you have obtained each night over the preceding week.

3.Avoid sleeping in, extensive periods of horizontal rest or daytime napping; these activities usually affect the subsequent night's sleep. 4.Get regular exercise every day: about 40 minutes of an activity with sufficient intensity to cause sweating. If evening exercise prevents sleep, schedule the exercise earlier in the day. 5.Avoid caffeine, nicotine, alcohol and other recreational drugs, all of which disturb sleep. If you must smoke do not do so after 7:00 p.m. 6. Plan a quiet period before lights out; a warm bath may be helpful. 7.Avoid large meals late in the evening; a light carbohydrate snack (e.g., crackers and warm milk) before bedtime can be helpful. 8.Turn the clock face away and always use the alarm. Looking at the clock time on awakening can cause emotional arousal (performance anxiety or anger) that prevents return to sleep. 9.As much as possible, keep the bedroom dark and soundproofed. If you live in a noisy area, consider ear plugs. 10.Use the bedroom only for sleep and intimacy; using the bed as a reading place, office or media centre conditions you to be alert in a place that should be associated with quiet and sleep. If you awaken during the night and are wide awake, get up, leave the bedroom and do something quiet until you feel drowsy-tired, then return to bed. Note: Pharmacologic (or any) interventions will be less effective if these guidelines are not followed. In mild cases of insomnia, sleep hygiene guidelines, practised consistently and together, may be sufficient to reinstate a normal sleep pattern.

Difficult sleeping for the last 3m OCD How did it start? Suddenly / Gradually? From that time is it all the time or “on and off?” Shift to “whom do you live with?” U: How did that lack of sleep affect your life? Give confidentiality. R/O: Depression,

Drinking (her or husband), “How much? How often? Does he drink more? What is the reason? Any change in your life? When your husband gets angry – does he start shout at you? (“Sometimes when people are drinking it can

Did you go to the ER? How often you go to the ER? Did he ever shout at you? Does he swear?/Shout?/Call your names? How does it affect your self esteem? Did he ever become anger to the extent that he becomes physical? Pushing? Did he ever force you to have sex against your will? Did he ever hit the children? Did he ever abused you in front of the children? Who’s controlling spending? (If she says that the children are safe – you can say that children are smart and realize that).

Counselling

Based on what you told me it is called “spouse abuse” it is illegal, it is a crime and against the law. You shouldn’t feel guilty about that. We know from studies that this situation will deteriorate, and without proper of help it might end badly. If you are concerned with the economic situation I’d like to know that there are a lot of resources. I’ll give the number of social support that We know from studies...he will have some restraining...usually situations might improve. Always give them follow up in three days. Back to Content 55 yo, believe that have strange feeling in hands. Do mental exam. Either organic, late onset of schizophrenia, not complying with medication INTRO: 3 ways: 1.How did it start?

OCD:

What were you doing at that time? What happened at that time?

Ms Franco 55/F strange feeling in (R) hand x 6 mo in ER talk to her for 10 mins Can U tell me about it? Is it one or (B) hands? How did it start? Right now,how do you feel/ Right now u look concerened,anything bothering U? U’re in the right place

What were U doing when it all started? Anything special happened at that time? Ask What events?....... Or Do you remember how it started 1st time? Is it all the time or off & on Any particular time of the day Any particular settings What is special in that setting? In your opinion what is responsible for it? May show a pic

It may be like a radiation for you,but not for me Where exactly do you feel it?

Anywhere else?Any weakness/numbess Ask for HOMICIDAL/SUICIDAL ideation Ask for Hallucinations: P=PSYCHOSIS

HALLUCINATIONS:

VISUAL HALLUCINATIONS: 9.Do you sense things that are not actually there? 10.Do you see things that others do not see? 11.What do you see? You look preoccupied REASSUARE HER THAT SHE IS IN SAFE PLACE

DO NOT LOSE NERVE

12.Can you describe what you see? 13.Does it have a message for you? 14.Does the message ask you to harm yourself? 15.How do you feel about it? 16.Is this the first time? AUDITORY HALLUCINATIONS: 12.Do you hear voices other people cannot hear? OR : c)If you’re alone & nobody with you, do you hear voices? d)Do you hear voices inside your head? 13.How many voices? 14.Are the voices familiar?

DO NOT LOSE NERVE

15.Do you recognize the voices? 16.Do they talk to you? 17.Do they talk about you? 18.What are they asking you to do? 19.Do they ask you to harm yourself? 20.Do they ask you to harm anybody else? If YES: 21.What is preventing you from doing this?........Screens for INSIGHT DELUSIONS: 8.Do you feel anyone wants to hurt you or harm you? If YES: WHO & WHY?

9.Anybody tries to control you? 10.Anybody wants to put thoughts into your head? (Thought Insertion) • Anybody wants to steal thoughts from your head? (Thought withdrawl) 11.Others can read your thoughts? (Thought broadcasting) 12.When you’re watching TV or reading the News, do you feel they’re talking about you? (Ideas of reference) 13.Do you think any part of your body is rotting? 14.Do you feel everybody is falling in love with you?

MOOD

ORGANIC: Since it is first time I’m seeing you.I’ve to ask you questions Any long term diseases?

Look for S/e of meds (Streoids,smoking,drugs) Head Injury Fever Csx: Look for Social Hx Past Psy Hx Self Care

Admit

If Pt asks: Am I crazy? Thre is no medical condt called crazy.Sometimes some pts have difficulty in handling their thoughts & this is called “Schizophrenia” MSE

APPEARANCE: 1.Well dressed 2.Well groomed 3.Dress matches weather 4.Given age matches chronological age BEHAVIOUR: 1.Agitated

2.Psychomotor retardation 3.Eye Contact 4.Co operative 5.Non hostile 6.No abnormal movts/Jerking/lip smacking C/SPEECH: 1.Volume 2.Tone 3.Fluency

4.Articulate MOOD& AFFECT: Mood;Subjective Sx in pts own words Affect (qarms) 1.Quality: Euthymic/depressed/elevated/Anxious 2.Appropiateness to thought content 3.Range:Full/Restricted/Flat/Blunted 4.Mood Congruence 5.Stability: Fixedt/Labile PERCEPTION: Hallucination Illusion THOUGHT PROCESS:

1.Coherence/Incoherent 2.Logical/Illogical 3.Circumstantiality/Tangentiality THOUGHT CONTENT: •Suicidal/Homicidal Ideation Low-- fleeting thoughts,no formulated plan,no Intent

Intermediate--More frequent ideation,well formulated plan,No active intent High --Persistent ideation & profound hopelessness/Anger,well formulated plan,active intent,believes suicide,homicide is only helpful option available • Obsession: Recurrent or persistent thoughts,impulses or images that cannot be stopped which is intrusive or inappropriate Cannot be stopped by reason & Causes marked anxiety & distress • Preoccuption: •Overvalued Ideas: •Ideas of reference: •Delusions:

•Magical thinking: •First Rank Sx of Shz:Thought insertion/T withdrawal/T broadcasting COGNITION: MMSE Level of consciousness Orientation in time/place/person Memory: immediate,remote,recent Attention & Conc Global evaluation of intellect: Intellectual Fns: INSIGHT: JUDGEMENT:

24 yo, brought by his roommate because hasn’t been himself in the last 10days.



D/d: 1.Ac. psychosis, 2.Substance abuse, 3.HIV, 4.Mania If started 10 days ago, why brought in today? (could’ ve been homicidal or suicidal) If carrying a book, ask Reason Ask Delusions for grandiosity :“Do you feel you’ve a special mission?--- if Yes Always ask what is the mission? & probe deeper & enquire about Delusions Mission imp May be Suicidal or Homicidal ideation



  17/M worried about contamination – wants to be admitted to get rid from it. 10min – counsel



Delusions: Dd: 1.Schizophrenia 2.Schiziod personality Disorder 3.Schizotypal PD 4.Isolated PD (older pt in 40s & usually delusions about fidelity)

Qns about Delusions DELUSIONS: 15.Do you feel anyone wants to hurt you or harm you? If YES: WHO & WHY? 16.Anybody tries to control you? 17.Anybody wants to put thoughts into your head? (Thought Insertion) • Anybody wants to steal thoughts from your head? (Thought withdrawl) 18.Others can read your thoughts? (Thought broadcasting) 19.When you’re watching TV or reading the News, do you feel they’re talking about you? (Ideas of reference)

MOOD:

How is your mood,is it down,Up or N ? ORGANIC:R/O Head Injury CSx: HIV/Meningitis Medications: Steroids,smoking,alcohol,drugs S/e of meds,Pt may have stopped anti psychotics due to Se

35 yo, believes that the RCMP chasing him.



Persecutory delusions. Reassurance about his safety. DDx substance abuse. INTRO;

Early on reassure pt that this is a safe place, & invite him to sit down As I understand you’re here because you have worries that the RCMP is chasing you. I want you to know that this is a safe place & please come & sit. I want to help you so please sit down Make sure he sits in front of you. Ask him:

•Why chasing? •How long chasing? •How affecting him? •How does he handle it? •Does he talk to anyone about it?

Here there is persecutory delusion Besides police does anyone else want to hurt him? Does he have special powers? FINISH the delusions Go to Hallucinations VISUAL HALLUCINATIONS: •Do you sense things that are not actually there? •Do you see things that others do not see? •What do you see? •Can you describe what you see?

•Does it have a message for you? •Does the message ask you to harm yourself? •How do you feel about it? •Is this the first time? AUDITORY HALLUCINATIONS: •Do you hear voices other people cannot hear? OR : •If you’re alone & nobody with you, do you hear voices? •Do you hear voices inside your head? •How many voices? •Are the voices familiar? •Do you recognize the voices? •Do they talk to you? •Do they talk about you? •What are they asking you to do?

•Do they ask you to harm yourself? Also ask for tactile hallucinations I see you’re scratching your hands Any other areas are scratching? When & How long?.....Pt will answer.... I do not know ....... Jump to cocaine

Do you smoke/Take alcohol/Drugs I f Pt stands, you stand, reassure him & bring him back & ask again about drugs Did you take an increased amt recently? How do you take it? Snort/Smoke/IV? If IV ask about CSx; MOOD R/o Mania & depression Suicide & Homicide If Pt leaves tell I want to file form 1 & call security

17/M worried about contamination – wants to be admitted to get rid from it. 10min – counsel



Delusions: Dd: Schizophrenia Schiziod personality Disorder Schizotypal PD Isolated PD (older pt in 40s & usually delusions about fidelity)

Qns about Delusions MOOD: How is your mood,is it down,Up or N ? ORGANIC:R/O Head Injury CSx: HIV/Meningitis Medications: Steroids,smoking,alcohol,drugs S/e of meds,Pt may have stopped anti psychotics due to Se

•A key feature of bipolar disorder is recurrent nonadherence to medication; including the patient in decision-making, together with psychoeducation, promotes a strong therapeutic alliance and enhances medication adherence. •Patients taking lithium need to maintain their usual salt and caffeine intake and monitor fluid intake and output, making adjustments in the event of unexpected losses due to vomiting or diarrhea.

•During acute manic episodes, patients may exhibit increased tolerance to lithium. •Advise patients taking antipsychotics about antipsychotic-associated body temperature dysregulation and strategies to prevent heat stroke (e.g., hydration, sun protection). •For lithium-associated cognitive impairment, check lithium level and thyroid function. Lowering the dose or using a slow-release formulation may improve cognitive function. •Patients who experience tremor while taking lithium may benefit from elimination of dietary caffeine, lithium dose reduction or addition of a beta-blocker such as propranolol or atenolol. •Patients who experience diarrhea while taking slow-release lithium preparations may fare better with immediate-release formulations,17 particularly the oral liquid citrate salt.18

Pt wants to discontinue his Li If stop Li Relaspe 1st time: disct Rx:40 – 60 % 2nd time:80% 3rd time:>95% Can control BP1 but not cure

 

Want s to stop Li as handwriting not like before



Ask if any other concerns .....

Seems reasonable.... INTRO:

As I understand, you’re her cuz you’ve been diagnosed with BP1 3 yrs ago & want to disct your Rx,during the next few minutes I will take Hx & towards the end hopefully we will reach a working plan Ask: Why do you want to discontinue? ASSES: MOOD disorder whether Mania/Depression Go back to mania specially when diagnosed Li if SE Asses: Psychosis Anxiety Organic

Past Medical Hx Fhx Social Hx Fhx of Depression & BP1 Suicidal 7 Homicidal ideation Self care COUnselling

INTRO

Can you tell me more about your decision? Why? Any other reasons? These seem reasonable enough concerns & I’m glad you’re here today to talk about it Let me ask some qns How would you describe your mood today? Even if he says good..... Go through DIG FAST Grandiosity:

Ask for opposite mood Do U feel Low MI PASS ECG 1.How were U Dsed as BP1? 2.What was done at that time? 3.Were U hospitalized? 4.Was there serious consequences? 5.Are you under reg F/U? 6.When was the last time you saw your Dr? Li 1.Which medications are you on besides Li? 2.How much Li? 3.Is it measure d on a regular basis?

4.What was the level? 5.Any new meds/ or increase in dose? 6.How do you feel about taking Li? Any SE

Have U got TSH measured? When was the last time it was measured? Do you feel cold? Inc wt/Dec conc? Drink more/Pee more? Any urine analysis? Screen for Ataxia:Any shakiness/falls/difficulty in balance? Nx/Vx/Abd pain? If TSh Inc ct with Thyroxine If Di early Stop later Ct with Thaizude GI Stop Tremor B Blocker

Have you ever discontinued Li in past few yrs? TRANSITON: I know you’ve been asked this qn before, but I need to ask these qns PSYCHOSIS ANXIETY Past MH

Fhx of depression/Suicide/BP1 How do u support urself financially? COUNSELLING:

Compare between Mania & Depression What is your understanding about Mania? Mania is a condt that affects mood,in which people feel elevated it is one of the mood disorders it is common. Most people have depression, where people feel low & lose interest & Rx is often Talk therapy & medications. The Rx for Mania is lifelong,similar to DM,in which we can control Sx,but not cure it.There is a lot of research going on & ne day we hope to find a cure for it. If you choose to discontinue it,your chances of relapse are high upto 60% Coming to Li levels if 1.2 upper level of (N) & we can decrease the dosea bit & see how it affects you. But you’ve to PROMISE me that at any time you spend more,sleep less etc contact me or go to ER ASAP. Pt may accept .

When it comes to writing Thought block is not one of the SE of Li,give it time ,& see if it improves If S/o depression it is the other component of BP1 & I will refer you to psy. Therapeutic Tips

•A key feature of bipolar disorder is recurrent nonadherence to medication; including the patient in decision-making, together with psychoeducation, promotes a strong therapeutic alliance and enhances medication adherence. •Patients taking lithium need to maintain their usual salt and caffeine intake and monitor fluid intake and output, making adjustments in the event of unexpected losses due to vomiting or diarrhea.

•During acute manic episodes, patients may exhibit increased tolerance to lithium. •Advise patients taking antipsychotics about antipsychotic-associated body temperature dysregulation and strategies to prevent heat stroke (e.g., hydration, sun protection).

•For lithium-associated cognitive impairment, check lithium level and thyroid function. Lowering the dose or using a slow-release formulation may improve cognitive function. •Patients who experience tremor while taking lithium may benefit from elimination of dietary caffeine, lithium dose reduction or addition of a beta-blocker such as propranolol or atenolol. •Patients who experience diarrhea while taking slow-release lithium preparations may fare better with immediate-release formulations,17 particularly the oral liquid citrate salt.18

21/2/2011

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Introduction to physical exam:



“... If it is after history taking. “Thank you for the information. Now I’ll do some physical exam...hopefully towards to the end we’ll reach a working plan...”

During the physical exam – talk aloud. Verbalize everything. Don’t fail to drape the patient. Doing after vitals and general inspection. Lack of empathy (Warm hands and stethoscope and try it on your arm). You warn the patient before the exam, but also before any manoeuvre. If there is painful area – don’t repeat it. If the patient having

34 physical exams, and 11 management stations



(ER):

Physical Exam: 1.CVS 1.1.Essential Htn for the last 30y, 65 yo for f/u 10m 1.2.35yo dgn recently with Htn, do focused physical exam (CVS) 5m 1.3.25yo recently HTN, relevant physical exam 5m 1.4.60yo, Pain in calf muscles – history and physical 1.5. 35yo palpitations, history and physical. 10m

1.6.30-40yo, Cardiac murmur. 5m. 1.7.70yo A surgery 3d ago doesn’t pass urine 4hours – 10m (do JVP and vitals) 1.8.50yo SOB, 3d ago had surgery, 5m focus physical exam (emboli) 1.9.Car accident 24 ago, SOB, P/E 5m (fracture, fat emboli)) 1.10.SOB for the last, surgery 3d ago, 10m 1.11.History of heart failure for the last 10y, 3d ago SOB, 10m physical exam 2.RS 2.1.Cough, for the last 3d, focused p/e 5m 2.2.Female Hx breast cancer, mastectomy, chemotherapy and radiation 5y ago, a week cough or SOB (Pulm. Fibrosis) 2.3.Coughing blood 1w, 67yo, history and p/e 10m 3.GI

3.1.Lower abdominal pain last 24hr, 22 yof, 5m focused p/e 3.2.35 yof, came to the ER abdom. Pain 2h, 3.3.22 yof Hx of Crohn, abdominal pain 24hr, 5m focused p/e 3.4.30 yom abdominal pain, 5m focused 3.5.61 yom Hx alcoholic patient vomits blood, 5m p/e 3.6.25yof, epistaxis, bruising in skin, hematologic exam (ITP) 4.Neuro

4.1.HIV positive, headache for the last week – do cranial nerve exam (wear gloves) 4.2.40 yo, Difficulty in vision, Hx and p/e 10m 4.3.Crooked face (Bells palsy) - hearing and than 7th nerve, 5m focused p/e 4.4.Weakness in the Rt. Or Lt. Hand – see the power, reflexes and tone, history and physical 10m 4.5.Diabetic foot – do physical exam, 5m (monofilament test – 10m exam) 4.6.Unconcious – do neurologic exam for , 5m 4.7.Shakeness in his Rt. Hand (Parkinson) – 5m 4.8.Back pain

5.M/S – all joints except elbow. 5.1.Neck (level of the lesion) 5.2.Shoulder pain 5.3.Hand 5.3.1.Laceration in the wrist 5.3.2.CTS

5.4.35 yom – Hip pain (gonorrhoea), otherwise 5.5.Knee – Osgood Schletter, Chondromalacia patella and osteoarthritis 5.6.AP cruciate ligament, 5.7.Ankle – counsel patient. There is no fracture or rupture of ligaments. 10m 5.8.Back pain 5.8.1.Acute (3d ago) 5.8.2.Acute superimposed on chronic (fracture on metastasis) 5.8.3.Chronic back pain (young – Ankylosing spondylitis, old – spinal stenosis or osteoarthritis)

Intro Vitals

GI (I, A, Per, PS-PD, ST), DRE, Pelvic exam for females RS (I, Pal, Per, Aus, ST) CVS (I, Pal, A, ST), PV exam and JVP in the neck MS (I, Pal (Temp, Tenderness, Crepitus), ROM, ST) one below and one above joint. Neuro (I and orientation, CN, U and LE, Coord., Cortical sensation) InsBulk/PulpTonePowerReflexesSensation SEADS (Swelling, Erythema, Atrophy, Deformity, Scars)

Vitals: BP, HR, Temp, RR (“Based on the vital patient is stable I am going to do...) If there are no vitals you will say “I am going to start my physical exam by measuring the vitals by taking BP, pulse, temp...) If there are only 3 out of the 4 parameters – “Before I proceed I’d like to know what is the temperature...”

Weight and height in pounds and inches. (5 feet is 150cm, 6 feet is 180, 5,6 is 165cm) General inspection: lying down comfortably, no signs of distress Specific inspection: SEADS for each joint (Is it OK for you to lower your gown... ) Neck – no scars, erythema, atrophy, + muscle contractions; Normal cervical and thoracic curvatures. Back – no SEADS. From side – normal cervical, thoracic and lumbar curvatures. Shoulders – both shoulders are symmetrical, clavicles deltoid and scapulae are in the same level and angle. Hand – SEADS + thenar and hypothenar muscles.

Hip – I’d like to have full exposure. Hip joints are deeply seated joints – I am looking for any obvious SEADS and gluteal folds on the same level, and mentioning the lumbar curvature.

Knee INSPECTION:

(Stand, walk and lie down). 1. Stands up:

By inspection 1.(B)knees are symmetrical 2.(B) knee jts are normally aligned 3.No genu varus or valgus. 2.ask him to WALK: & look for: 1.Gait 2.popliteal fossa.(no bulge in popliteal fossa) 3.LIES DOWN:– SEADS

(B) Quadriceps muscles are in the same bulk. Ankle – SEADS, no open fracture no bruises. The last thing in the ankle is the gait. Gait – do in every joint besides shoulder, arm and hand. TTC (Temp, Tenderness, Crepitus)

If the patella is the same temp as the rest of the knee – there is inflam. Both patellae are the same temp. And colder as the rest of the leg. Quadriceps, suprapatellar pouch, patella (press and swing) – there is no signs consistent with chondromalacia patella, along the ...press on the collateral ligament, press to the back, when bending the knee: Up, Down, and In. Crepitus – no crepitus. Effusion – Bulging sign and milky test.

Bend your knee all the way. Normal or limited flexion. Can you push against my hand and pull. ST – cruciate ligaments, medial/lateral, and anterior posterior. Medial and lateral collateral ligament – varus and valgus stress test. McMeri test for the meniscus. Examine the other knee, pulse (popliteal). Examine above and below the knee (just mention it).

Patrick’s test (sacroiliac joint) and Thomas’ test (fist in the lumbar region – in case of osteoarthritis they need to do flexion by increasing their lordosis and feel less pressure).

KNEE



Intro: Good afternoon Mr XXX as I understand you’ve a pain in your (R) knee for the next few minutes I will be examining you,& if you feel any pain please let me know. I will also be reporting my findings to the examiner. Is that Okay with you? Can I proceed? Can I get the vitals please?

On General examination:

Pt sitting comfortably in no obvious distress Mr xxxx Can you please stand up? Can you please hold up your gown? By inspection 1.(B)knees are symmetrical 2.(B) knee jts are normally aligned 3.No genu varus or valgus. Can you please WALK: & look for: 1.Gait 2.popliteal fossa.(no bulge in popliteal fossa) Thank you, Could you please turn around walk back & lie down, I’m going to drape you LIES DOWN:– O/Inspection: 1.SEADS

2.(B) quadriceps muscles are in the same bulk I’m Going to feel your knee PALPATION: TTC (Temp, Tenderness, Crepitus) 1.Both patellae are the same temp & colder as the rest of the knee. 2.(B) Knees are symmetrical & there is no increase in temperature 3.(B)Quadriceps are normal in bulk 4.Suprapatellar pouch (N)

5.Patella (press and swing) – there is no signs consistent with chondromalacia patella, 6.Go along patellar tendon & end on Tibial tuberosity 7.No tenderness of T Tuberosity 8.press on the Medial collateral ligament, 9.press on the lateral collateral ligament 10.press to the back, for pop[liteal fossa Bend the knee: Open joint fully 11.Up for Femoral condyles 12.Down for ,Tibial condyles

13.In for the lateral & medial meniscus Relax your knee,I’m going to move your knee & examine for crepitus EFFUSION: •Eliminate the suprapatellar pouch •Press on patella ------->Patellar tapping ------>Bounce = Fluid •No bounce on patellar tapping •Bulging sign •Milking Sign ROM; Can you please bend your knee all the way (N) flexion Full flexion & extension POWER: I need to examine the stability of the knee: 3 tests:

1.Medial & lateral collateral lig Varus & Valgus stress test 2.Cx ligament: Ap drawer test 3.Meniscus : Mcmurray test Examine other knee POpliteal pulse

Dorsalis pedis pulse I would like to examine one Jt below & one jt above Ankle joint & back

HIP JOINT



Intro: Vitals G/E: Would you please stand up? Do you need help? Turn to (L) side------ go to back Ask examiner: Can I have full exposure? Can you please Roll up shirt,I’m going to look at your hip INSPECTION

The hip is a deeply seated joint,however I’m looking for SEADS (B) hips are symmetrical (B) gluteal folds are same level Lumbar curvature Normal PALPATION: I’m going to feel your joint,plz inform me if you’ve pain: 1.SI jt (N) 2.Post superior Iliac spine (N) 3.Iliac crest (N) 4.Ant superior iliac spine (N) 5.Greater trochanter (N) Plz walk to the wall,do you need help? Gait (N) No limping Can you please turn & come back? When standing look for EXTENSION Trendelenbergh test Can you please lie down DRAPE

I would like to continue my inspection anteriorly SEADS PALPATION: 1.Along inguinal ligament 2.Head of Femur 3.Symphysis Pubis Examiner will say (N) (Inspection & palpation done) ROM

1.Extension done when standing 2.Bend knee to abdomen as much as you can (flexion) 3.Abduction & adduction 4.Passive & active length Discrepancy in true length Hip lesion

Patrick test Thomas test Sensory fn

Knee joint & Lumbar joint

  SHOULDER
 

Frozen shoulder – active and passive are limited.

Rotator cuff – four muscles.

•Complete tear (initiation of abduction is lost 1st 30 -60) swing the hand or tilting and doing flexion and abduction. Cannot initiate and has painful arm and dropping.(DROP ARM) •Partial tear or tendinitis or impingement with same presentation (u/s or MRI can help to differentiate between them). Painful arch – can move, but it may ease him to turn the hand in supination. The empty can test – his arms fall. •Anterior dislocation – apprehension test positive. For posterior dislocation – push the elbow backward. •Bicepts tendinitis – supination and flexion (Jargonson test). Flexing against resistance (Job’s test). •Infraspinatus and teres minor – external rotation against resistence. Internal rotation for subscapularis (lift-off test).

INTRO: Is it Ok to untie your gown & is it Okay to kep it in your lap? INSPECTION: 1.(B) shoulders are symmetrical

2.(B) Deltoids are symmetrical 3.(B) clavicles are at same angle 4.(B) Scapulae are at same level 5.No SEADS PALPATION: I’m going to feel your joint, 1.Temp (N) 2.I’m going to press your joint 3.Sternal notch NT 4.(B) Sterno clavicular joint NT 5.(B) Clavicles NT 6.Acromio clavicular jts NT I’m going to focus on (R) shoulder & then (L) shoulder Press on: 1.Acromian 2.Spine of scapula till medial aspect of scapula 3.Tip of scapula 4.Spinal process of neck 5.Insertion of Supraspinatous NT (Greater Tuberosity) 6.Glenohumeral joint NT Sulcus Sign _ve (Pull down on shoulder) CREPITUS Relax I’m going to move your shoulder & feel the movts MOVE TO NECK & examine neck To ENSURE that shoulder pain not related to neck pain

ROM:

Please put your gown back stand up & face me Would you mind copying me Full flexion & extension Push back (extension) Int rotation Cross arms--- Adduction Move to sides all the way up to the head------ Abduction Ct moving down. Hold below (No painful arc) No drop arm SPECIAL TESTS: POWER PULSE

Chronic back x 6m0



INTRO: VITALS G/E

Can you please stand up? CAN YOU PLZ UNTIE YOUR GOWN? INSPECTION: If Hx,:1st inspection of face 1.Eyes for rednes 2.Mouth for ulcers 3.Nails: No pitting/ulcers/or skin changes Look at back Curvature ---Side:Normal cervical,Thoracic & Lumbar curvatures Back: No Scoliosis SEADS

PALPATION:

Warm hands & tell Pt: I’m GOING TO FEEL YOUR BACK, tell me if you feel pain Feel temp

Press Spinous processes individually Identify C7 Iliac crest: L 4-5 Press; Para vertebral muscles SI Jts TIE THE GOWN BACK & Ask Pt to lie down DRAPE I’d like you to do some movts for me: ROM

1.Can you touch your toes with your fingers without bending knees? 2.Arch your back backwards without bending your knees 3. Can you slide your arm along your thigh as low as you can? 4. Can you cross your arms & rotate the shoulder (Fix the hip) “Because I noticed you have restricted ROM of movements in all directions I’ll do a test called Shubert test. I will draw some lines on your back which are washable Dimples of venus – sacroiliac joints for line A 10 cm above ----- Line B 5 cm below ------Line C

Try & touch toes without bending back the difference from line B it should be at least 15cm. Less than 15cm – it is restricted. The 5cm below is for control WALK to wall: Gait (N) No limping Stand against wall Occipital from wall test.(When there is Shubert test positive ) Stand On toes – S1, Stand on heels L5. Pitting changes in the nails, psoriatic changes. CAN You please lie down? DRAPE SLR

Patrick test Listen to his heart for Aortic Insuff. Chest expansion – measurement in max inspiration and expiration (changes should be more than 5cm).

ACUTE BACK PAIN



Intro: Always ask Pt if he prefers to lie down or stand OCD: ONSET:

What were you doing at that time? Did you lift heavier than usual? Did you hear a snapping sound? Did you have to stop what you were doing? C PQRST: R: Does it move to the leg?,reach toe or thigh? Which bothers you more,The Leg or Back? EMPATHY........... Did you try any pain killer? A &A:

Lying down? Stretching? Bend/Move? U: V; ASx: 1.Weakness 2.Numbness 3.Tingling 4.Loss of balance & falls 5.Do you need to drag your foot? 6.How about Urine & Bowel symptoms: Some patients with similar condition may soil underwear 7.Numbness in buttock area? 8.H/O trauma to back?

9.Urinary: Dysuria/Flsnk pain? SOCIAL Hx:

Smoke Alcohol Drugs: ......Particularly IV drug use PE: G/E:

Vitals please

Can you please turn to side (so examiner can see) Can you please untie your gown? Dorso lumbar spine looks (N) curvature From Back: No scoliosis SI Joints appear (N) Tie gown ROM:

Forward flexion & extension WALK to bed & wall (Make sure that Pt does not FALL!!) Walk on heels & toes (support Pt) I’m going to raise your leg, please lie down & if it causes pain please let me know Can you please lie down? SLR SENSORY:

Start with Little toe:S1 1st Web:L5 (common peroneal nerve) Medial malleolus:L4 Knee:L3 Mid thigh:L2 REFLEXES: Knee Ankle Clonus

Babinski DRE Femoral stretch test End with Dorsalis pedis PULSES

Red Flag” Symptoms/Signs in Assessment of Low Back Pain

Condition Symptoms/Signs Investigations Herniated Nucleus Pulposus Positive SLR (leg pain at < 60°); MRI of lumbar spine weak dorsiflexion of ankle (L4-5) or great toe (L5-S1 or L4-5); reduced ankle reflex (L5-S1); reduced light touch in L4, L5 or S1 dermatomes of foot/leg1

Cancer Age > 50; previous cancer history; Positive laboratory tests unexplained weight loss; failure to (including elevated ESR, improve after 1 mo therapy2 reduced hematocrit) 2 and imaging showing erosion or blastic lesions

Spinal Osteomyelitis Intravenous drug abuse; sources of Positive laboratory tests infection (e.g., skin, teeth, urinary and imaging tract, or indwelling catheter); fever; vertebral tenderness3 Spinal

Fracture/Compression Fracture Age > 50, female gender, major Positive laboratory tests trauma, pain and tenderness, and a including plain x-rays distracting painful injury;4 also consider a history of osteoporosis or corticosteroid use Cauda Equina Syndrome

Acute urinary retention or overflow Emergency laboratory incontinence; loss of anal sphincter assessment and imaging tone/fecal incontinence; perineal numbness; change in sexual function; weakness of legs1

Factors Adversely Affecting Prognosis of Low Back Pain Psychosocial Factors Mental Status Indicators of Significant Anxiety or Depression

1.Duration of work absence 2.High levels of self-reported functional disability 3.Self-report of extreme pain and constant pain in multiple body areas 4.History of prolonged sick-listing after previous injuries 5.Prior history of absenteeism 6.Delays/obstacles in work re-entry process 7.Patients who believe that they will never return to work 8.Adversarial attitude toward employer 9.Long-standing history of psychiatric distress or maladjustment

1.Insomnia or nightmares 2.Irritability

3.Withdrawal 4.Panic episodes or anxiety during the day or night 5.Persistent tearfulness 6.Poor concentration 7.Inability to enjoy (anhedonia) 8.Poor appetite/weight loss 9.Poor libido 10.Thoughts that ―life is not worth living‖

NECK EXAM



INTRO: Vitals Pt stable G/E: INSPECTION: I’d like to take a look at your back, can you please untie your gown? (N) Cxal curvature---- Look from side look from back

SEADS PALPATION: I’m going to feel

1.(N) Temp 2.Press along individual spinous proceses (C1 to C7) 3.P Vertebral muscles 4.Trapezius 5.Sternocleido mastoids 6.Mastoid process 7.LN

8.Thyroid (ask the patient to swallow) ROM: I’m going to examine ROM Copy me, 1.Touch chest to chin-----> Flexion 2.Look at ceiling -------> Extension 3.Turn to R/L Rotation 4.Touch shoulder to ear ---- R & L Lateral flexion 5.Check Streno Cleido mastoid by pressing against my hand & push to back (? Not done!) 6.Neck pain not associated with muscle spasm 7.Can you cough? ------ “No neck pain with Valsava’s manoeuvre” Part of my exam is to check your UppExt: Can you roll up your sleeves? INSPECTION:

1.(B) U extremities are symmetrical 2.No abnormal posture or contracture 3.Bulk is symmetrical PALPATION: See & feel deltoids, biceps, Triceps, forearm, Thenar & hypothenar muscles TONE: WRIST:

No cogwheel rigidity Elbow

No Pb pipe No clasp knife rigidity SENSORY: C6 C7 C8 C4 ------ REFLEXES POWER: In U/E Deltoid Biceps

Fan fingers Power of thumb SPECIAL TEST: Spurling test Ask Pt to stand: Check Clonus & gait CNErve exam

  HAND Laceration

Hx: 1.AMPLE + Tetanus 2.Mood 3.Handedness (occupation : can affect if Pianist, Speech therapist, Plastic surgeon) 4. X ray

5.5. 6.Irrigate with NS 7.Antibiotic prophylaxis 8.NPO INTRO:: As pt has an injury,I would like to get gloves for protection Greet Pt & ask for vitals G/E;

Remove bandage & describe the wound: Position: wound on palmar aspect: 3 cm in length/2mm width/depth cannot be assessed 5-10 cm proximal to wrist on Volar aspect No active bleeding/No oozing/Margins clear & not elevated (B) hands are symmetrical SEADS Colour similar I’m going to FEEL: Temp (B) hands is normal (N) Capillary refill

I’m going to feel your hands to see if there is damage to the arteries (N) radial artery & ulnar SENSATIONS: Lt touch Ulnar/Median/Radius Tenderness to PALPATION: Distal radius/Styloid process/distal part of ulna & styloid process/base of thumb Press carpal bones & metacarpal bones ROM: try to do on table & not move elbow Ulnar deviation

Radial deviation MPOTOR FN OF MEDIAN N: OK Sign Ulnar N :Able to hold peice of paper betn Adducted finger & resist pulling RADIAL N: Extend thumb Thumbs up THUMB: Make a fist & fan out fingers Can you touch ........your thumb to the tip of your little finger? (flexion) Take it all the way to other side ? (extension) Point to ceiling (Abduction)

Put close to your hand?(Adduction) Touch thumb to tips of fingers? (opposition) FLEXION: Can you bend your fingers one by one?----- Flexor digitorum profondus Flexor Doigitorum superficilias

CTS



Pain in (R) wristy x 2 wks: Hx & PE OCD PRTY UV A&A ASx CSx D/d: 1.CTS 2.Spinal stenosis/OA/Cervical disc herniation 3.TIA 4.Thoracic outlet syndrome OCD: O: C:

How often? Daily? Since when daily? Before that? At Night? D: How long each attack? What brings these attacks?

What relieves it? What do you do for a living? PQRST:

P: Can you show me where it is? Q; S: U; V: A & A:

Movts/Medications/Repeated movts Local Sx: Swelling/Numbness/Weakness/Other hand/Leg/Bladder & bowel disturbances CSx: AETIO: I’ve to ask you qns as to the presence of any condt that might have caused this: 1.Hx & Sx of DM: 2.Hx & Sx of Hypothyroid 3.Hx & Sx of Acromegaly

4.Trauma 5.Fall 6.HX of RA D/d: Neck pain Past MH: HTN/any long term disease Social Hx;SAD Fhx: Thank You for this information,I will now proceed to the PE GE: INSPECTION: 1.(B) hands are symmetrical 2.No SEADS

3.No Bouchardfs nodes 4.No Swan neck deformity 5.(B) Thenar & Hypothenar muscles equal bulk FEEL: 1.Temp & capillary refill 2.Palpate distal part of radius of hand 3.Bulk of thenar & hypothenar muscles ROM of wrist THUMB: Power check against resistance,pu;ll up & down & pull Hook thumb ….. BICEPS: Check Power & Reflex NECK: ROM to R/o C6 SENSORY: 1.Little finger :Ulnar

2.Ring Finger:Ulnar aspect for Ulnar nerve & radialaspect to R/o median nerve 3.2 POINT DISCRIMINATION: Only in Index finger SPECIAL TESTS: 1.Tinel’s Tap at medial aspect of wrist x3 times Ask if feels numb 2.Phalen’s sign PULSE: Radial T

TREMORS

PARKINSONISM

INTRO: Vitals: G/E:

Pt is sitting There is an obvious tremor in (R) hand (N) elbow

No tremor in shoulder

Ask patient to count from10 to 1 backwards: & observe the tremor.... •Tremor does not disappear on mental activity but increases, which is consistent with Parkinsonism, & R/O Anxiety related tremor Please extend arms & fingers: •No fine tremors R/O Thyroid disease •No flapping tremors R/O Liver disease •Can you touch Finger to my finger & then to your nose? No intention tremor R/O Cerebellar disease

There is no dysdiadokinesia Pt has a limited facial expression Limited eye blinking No drooling

INSPECTION:

Tremors in (R) hand, which are pill rolling & involve the (R) arm Pt does not have tremors in (L) hand, arm & shoulder NO head nodding I want to examine the TONE: •Cog wheel

•Pb pipe •Clasp knife Ask pt to please stand There is difficulty in initiating movt Stooped posture Decreased arm span Festinant gait Turns in block Ask Pt to say: British Constitution (N) articulation

Ask Pt to write; Micrographia I want to check for orthostatic hypotension Difficulty in rapid alternating movts: 1. 2. 3. I would like to arrange for a MMSE which can happen later.

 

HIV Pt with HA/PE (Cranial nerve exam)



1st nerve. (Coffee and ammonia). I’m going to skip the first nerve. I’ll ask the patient if he has any difficulty smelling. 2nd nerve.: OPTIC NERVE (5 tests):

ACUITY:

Ask Pt for best vision or if he wears EYE GLASSES

Hold Snellen’s chart with (R) hand & cover Lt. eye. Choose a mid-line, jump two lines below, and finally last line. COLOUR VISION:, then the other eye, change eyes, ask colour first in a reversed order and if he sees in the same intensity. Go straight to last line and ask to read backwards. VISUAL FIELDS:

(DDx one eye blindness, bitemporal and homonymous hemianopia) PUPILLARY REACTION: I am going to shine the light in your eyes it might might bother you: first shine at the (R) Look at the (R). Eye, second shine in rt. Look at left side, 2 shine light in eyes & see pupillary reaction : 2-3nerve (2- afferent, 3-efferent) FUNDOSCOPY:

verbalize (DM: microaneurysms, cotton wool spots, neovascularisation; Htn: flame hemorrhage, disc edema, nipping of veins)

3rd, 4th and 6th

I am going to examine the nerves which cause movement of the eyes. INSPECTION:

(B) eyes are symmetrical, No deviation. No head tilting (4th nerve), No ptosis (3rd nerve), No nystagmus.

Tell patient to look at the tip of pen and follow with eyes and when you see double vision please tell me.

Start from middle and create an H. Then go to centre and check conversion. “Normal extraoccular vision, no limitation, no nystagmus.” 5th nerve: motor and then sensory. INSPECTION:

No atrophy in temporal and masseter area. I am going to examineSENSORY:. This is a piece of cotton, I’ll put in on your chest – this is how it feels. Now I am going to touch different parts in your face while your eyes are closed. Whenever you feel it touches you tell me. Then ask him if it is the same feeling. MOTOR: clench teeth and relax twice. Feel the bulk of the temporal and masseter – they should be similar bulk. Can you push your jaw against my hand? 7th is mostly motor. Sensory for the tongue (anterior 2/3). Corneal reflex efferent limb.

INSPECTION: Face symmetrical, Normal nasoliable fold, No drooling,

No deviation of angle of mouth. Now copy me: raise your eyebrows, frown, close your eyes and don’t let me open them, puff cheeks and don’t let me blow out, show your teeth, and whistle. I would like to check corneal reflex in the eye 8th nerve.

I am going to whisper words in your ear. Repeat after me (“horse” and “house”). 9th and 10th

1.Normal voice, no hoarseness.

2.Swallow for me – swallowing is normal. 3.Say AHAA – soft palate symmetrical, uvula is central. 4.Gag reflex I’d like to do.

11th nerve – shrug your shoulders (“Normal trapezius”). Turn your head to the right against resistant and feel the bulk of the sternocleidomastoid.

12th nerve – no atrophy/ fasciculation of the tongue no deviation of the tongue. Wiggle your tongue left and right.

Unconcious Patient



INTRO: Hello, Mr….DO you hear me. If you hear me open your eyes. I am Dr. … one the physicians working in the clinic. FIRST CHECK PUPILS:

Pupillary reaction – pupils are round and symmetrical and reactive. Not dilated or constricted. There is no pupillary discrepancy. If one is reacting & the other not reacting – call neuro. If you hear me – can you move your eyes up and down? “There is no locked-in syndrome”. Vitals (Cushing triad absent; If the patient has fever we will verbalize it). GCS Cranial nerve:

1.2-fundoscopy, 2.2-3 – pupillary reflexion, 3.3-4-6 – eye deviation, 4.5-7 – corneal reflex, 5.7 – inspection of face symmetry, 6.9-10 – gag reflex Upper extremity:

Inspection (symmetrical, normal position, no movement, no contractures), tone, reflexes (biceps, triceps, brachioradialis) Lower extremity:

Inspection (symmetrical, normal position, no movement, no contractures), tone, reflexes (knee, ankle, Babinski) Meningeal signs

Neck stiffness, Kernigs, Brudinsky Babinsky Special test: Caloric test, Dolls eyes



ER



Trauma Non-trauma Hx + Transition A B C

D AMPLE

Head to Toe Orders ABCD History of present illness CC PQRST (Head to toe) ASx Α PMHx (Risk Fcts) Focused P/E Orders

In ER don’t be comfortable till after primary survey and IV lines. If non-trauma patient in ER – you do primary survey (shortened), more time on history and focus on CC.



Case of Trauma



I’d like to initiate ATLS protocol and I’d like protection to my team and myself (gown, goggles, mask, and gloves).

When walk to patient ask the nurse: How is the patient doing? What was done till now? If not wearing collar – tell nurse to fix the head, tell patient not to move “we need to fix your neck collar for your neck”.

Take a small history: “how do you feel right now?” (to see if he can talk). If complains of severe pain (empathy: I can see you are in pain, please bear me with me for a few minutes, as soon as I can I will give you a pain killer. At the moment I want to make sure you are stable for that reason, I am going to give some orders to the nurse, and as soon as I am done I’ll ask you more questions).

A - Airway

Please open your mouth. Mouth clear, the Flip your tongue: “there are no clots, foreign bodies, broken teeth, and Patient is talking to me – that mean airways are patent.

B Can I get the saturation?”

Give oxygen. If saturation is 95% than you give oxygen – ask if the saturation improved. Oxygen + saturation is a part of B.

Open the neck collar and look for trachea deviation, Jugular vein. Trachea J Veins Air Entry Heart Sounds Normal Central - Bilateral S1, S2

Tension Pneum. Opposite side Increased Decreased same side S1, S2 Hemothorax Opposite side Low/Normal Decreased same side S1, S2 Cardiac

Tamponade Central Increase Bilateral Muffled Pneumothorax – large bore needle in 2nd intercostals, midclavicular line, upper margin of the third rib.

Hemothorax – insert chest tube in 5th intercostals space mid-axillary line. Ask nurse “how much blood” (If > 1.5litre – ask for thoracic surgeon, also if greater than 800cc in 4 hours). If less – monitor.

Cardiac tamponade – ask for thoracic surgeon. Pericardiocentesis – needle in mid-xyphoid 45 degrees towards the tip of the scapula and look for blood. Continuous ECG. C

Vitals (every 10 minutes), and blood orders. “I’d like to get the vitals.

Comment if hypotensive tachycardia. I’d like to start 2 IV lines 16G in both anti-cubital fossa. 2 litre bolus Ringer lactate in one side, and from the other take blood. If no improvement after 2 litres – give another bolus. If deterioration in vitals – give blood. Finger prick glucose; BLOOD for: •CBC, Lytes, Group, Cross match, • INR, PTT, LFT, BUN, Cr, •Toxoc screen, Alcohol level.

If unable to get the IV line – insert intraosseous line (IO). •Order 6 units of blood: 2 O positive for male or negative for female in reproductive age and add 4 units of cross matched blood (pRBC). •Continuous ECG±cardiac enzymes (troponine, cpk-mb), Ask the change in vitals again & results of blood glucose.

Ask if 2litres were given. If stable – OK. If UNSTABLE:– look for source of bleeding. Start with ABDOMEN:

INSPECTION: listen, and palpation. If bruising – ask for surgical consult stat. If not available ask for FAST. If technician is not available – then DPL (Diagnostic Peritoneal Lavage). Then go for the

PELVIS:– I am going to press on hips to see if there is any pain. If complain of pain tell “I suspect pelvic fracture” Wrap sheet and call ortho stat. Look at the LOWER EXTREMITY: No internal/external rotation, feel there is any pain, difference in the legs. If you suspect fracture ask for Thomas splint and check the pulse before and after. Log roll – check for spinal process and DRE.

D D1- Deficit – Gross Neurological:

Shine light to both eyes “Both pupils normal size reacting to light. Can you squeeze my finger, wiggle your toes. Touch his sides of both upper and lower limbs – can you feel my touch. “Patient is grossly neurologically intact.” If unconscious – check papillary reaction and assess GCS. D2 – universal antidote Thiamine, Glucose,& Naloxone. D3 – specific antidote.

AMPLE Allergy Medication

PMHx Last meal, Last tetanus shot, LMP (if female) Event – describe the event (Rear end, T bone, Head on); Were you driver/passenger/alone? Have you had any head trauma? Do you remember anything before or after the event? Do you have nausea/vomiting/headache. Head-Toe examination

Orders

Hypertension/Secondary



As I understand you came here today because you were diagnosed with increased blood pressure. I’ll do a physical exam on you. Can I get the VITALS:please?

1.Patient have (B)systolic & diastolic blood pressure raised. 2.Patient does not have tachycardia, r/o pheochromocytoma and thyrotoxicosis. 3.Patient does not have bradycardia – r/o hypothyroidism. 4.I’d like to compare BP in upper and lower extremity to r/o coarctation of aorta. 5.I’d like to r/o orthostatic hypotension for pheochromocytoma. 6.Check orientation: Time, Place, and Person On general examination: Patient sitting comfortably •No sign of truncal obesity • No cervical fat pad. •Face is symmetrical

•No moon like face

EYES:

•Normal eye brow, •No puffiness around the eyes •No exophthalmus, •Please Follow my finger – there is no lid-lag or lid retraction. •Sclera for anemia or pallor. •No xanthelasma or arcus senilis • On fundoscopy there are no signs of Htn.

•No loss of visual fields (acromegally). NOSE:

•Nose OK (septal perforation in cocaine abuse).

HANDS:

•Symmetrical, •skin normal not dry or moist, no sign of drug abuse (needle puncture). •Normal capillary refill, •No clubbing •No nicotine staining. •Please stretch your hands – no fine tremor. •Pulse – regular, normal volume and contour. •Compare both pulses. (When lies down – take radio-femoral delay.) • Abduct shoulders to check proximal weakness for Cushings.

NECK:

•feel thyroid, swallow, •ask patient to lie down, put bed at 45 degrees and ask for JVP. • Check for carotid bruit (first listen than palpate)

BACK:

•Listen between scapula for collateral circulation and bruit (COA) • Base of lungs for creps and heart failure. •Press on sacrum and ankle for edema. CHEST: (lies down, please lower your gown) • chest is symmetrical. •No obvious pulsation. •I am going to feel. •Feel for apex beat, fine and identified PMI position and size, not enlarged not displaced, not sustained.

•No parasternal heave. •Listen to mitral area – normal S1, S2 •Move to bell and lie on side: no S3 and S4 ABDOMEN: •abdomen non-distended, symmetrical, no pulsation, no striae, no caffe au lait, no obvious masses.

•I am going to listen to the abdomen. 2 inches above umbilicus is the aortic bruit, renal is 2 inches on the same level, and the iliac are 2 inches below on 45 degree below. •Tap, feel dullness in renal area for masses. No supra-renal masses. • Femoral-radial delay, •No peripheral edema. Neuro: Kneel on chair and do ankle reflex a Quick neuro.

 

P/E of CVS



INTRO: VITALS: (Thank you for the Vitals)

Both Sys and Dia BP are elevated, HR is normal. Orientation: time, place, person G/ E:no obvious obesity HEAD: Eyes - ±pallor/arcus senalis, no xanthelasma Mouth: no dehydration FUNDOSCOPIC: exam

HAND:Temp/Capillary refill/Clubbing/Nicotine stain

Pulse: regular/normal volume and contour NECK: at 45o look for JVP, listen to carotids one by one, then palpate carotids CHEST: ask to lower gown INSPECTION: Sit and look for pulsation PALPATION: PMI Feel apex/thrills/heaves

AUSCULTATION: Aortic/tricuspid/MV, lay patient on left side, no S4 Sit up and lean forward, breathe out and hold it – listen if there is aortic regurgitation (?) Listen to base of lung Press on sacrum for edema. Ask patient to lie down on bed ABDOMEN: listen to bruit (aortic, renal and iliac) LOWER EXTREMITY: temp, capillary refill, dorsalis pedis and peripheral edema

Three places you look for orientation:

•Volume status •Malignant hypertension •Hypoxia and SOB

Volume Status



79 Hip replacement 3d ago, nurse asked to come and see, not passed urine for four hours. Do Volume status exam. INTRO:

VITALS: (and mention that BP should be done twice – while lying and sitting) After measuring BP in one position, there are two minutes before you measure the second position, meanwhile you do (the cuff of the BP should be on the same level of the heart). Width of cuff is equal to 40% of circumference of arm. 1.ORIENTATION:Time, Place, and Person. 2.Listen to the base of the lung. 3.Look for sacral edema.

4.Look for sclera for pallor. 5.Mouth: open and look for dehydration. Flip tongue for central cyanosis. 6.Look for hands, skin (moist and dry). 7.Capillary refill – should be less than 2s. Measure HR again and BP. If there is no increase in pulse more than 20bpm and no decrease in SBP more than 20 or DBP more than 10 – there is no orthostatic hypotension. If one of them is positive – Orthostatic hypotension.

Put patient at 45o to do JVP. Press on base to see if JV disappears. Measure. Take deep breath and hold – Kussmaul Sign absent. Untie the shirt and do hepato-jugular reflex. INSPECTION – S3 and S4 and all cardiac exam. ABDOMEN: percussion at suprapubic to see if bladder is full.

Pedal edema, than look at examiner and ask for: input-output chart & weight charts. (If there is cathter:) I’d like to make sure that the catheter is not kinking. Back to Content PVD

Pain in calf for three months. Vitals (“patient is stable”), if patient is wearing socks ask him to remove them. INSPECTION: (B) Feet: SEADS+3: •Normal hair distribution • Skin non-tight and shiny •No hypertrophy of nails

PALPATION: (I will feel your feet): •Peripheral temperature •Capillary refill

•Pulse (both sides): DP, PT, Pop. & Femoral. Drape the patient and listen to his abdomen for bruits. Feet – LIGHT TOUCH SENSATION: Bergers test – raise legs for two minutes – any you feel tingling/numbness tell me. After two minutes tell: “no pallor, pain, numbness, tingling.” Sit up and dangle his feet – “No rubour on depandance.” I would like to do ANKLE BRACHIAL INDEX

Diabetic Foot



Intro (As I understand you are here today cause you have DM for 2 y and ulcers in your Rt leg. I have to do a P/E) Vitals – stable. Drape and remove socks. INSPECTION:

Look at sole of foot. Ulcer – 3cm in diameter, round, margin not elevated, no active bleeding or oozing, located at base of 1st metatarsal. I am going to look for other ulcers at the base of the toes (Between medial and lateral maleolus.) Check SEADS + 3. PALPATION: Temp and capillary refill.

Shift to NEUROLOGICAL EXAMINATION: LIGHT TOUCH SENSATION in glove and stocking manner. Start with big toe and go to level – and than up and down until finding the right level. Light touch absent or decreased at a level to distal point. For example – above wrist. And then say to the patient: “Thank you and open eyes.” POSITION SENSE: close eyes and move the big toe up and down five to six times. “Thank you. Open your eyes.”

VIBRATION SENSE: tuning fork – put on sternum to show how it feels, then put it on the 1st interphalangeal joint. If doesn’t feel – vibration sense absent. Start with first joint, and second joint (you check vibration also for (1) medial maleolus, (2) tibial tuberosity, anterior superior iliac spine, sternum, chin, and forhead). (1) and (2) are for spinal injury. ANKLE REFLEX:

MONOFILAMENT TEST: press on sole or foot. Feel or no-feel. Increase the pressure & bend the monofilament. “He has lost light touch and pressure.” But if feels when pressure, say: “pressure present but light touch gone.” You check the same way in 9 points on the sole.

PULSES: DP, TP Auscultation (?) and ABI (Ankle-Brachial Index) Acute Abdomen, Physical exam

Intro

General inspection: the patient is lying comfortably and I see no signs of distress. Can I get the vitals please?

The patient is stable, normal temperature, BP and HR. You are going to face – can I take a look at your eyes: there is no jaundice, no sign of anemia. Please open your mouth – there is no sign of dehydration and obvious ulcer in the mouth. Upper extremity: capillary refill is normal.

Abdomen (drape appropriately): please move the cover – by inspection: the abdomen is not distended, umbilical inverted, abdominal moves with breathing, no scars, no bruises. Ask patient to look aside and cough twice (once look at his face to see for cough tenderness and then for abdominal bulging).

Now I am going to listen (warm the sthetoscope): “Normal bowel sounds, no bruits – aorta, renal, and iliac.”

Percussion: I am going to tap – show me where it pains. First tap away from painful area, than tap over the 9 areas – the painful area last. Pulpation: I am going to feel – no tender in epigastric/Rt. And Lt. Hypochondral/Rt. And Lt. Iliac regions/ Umbilical / Suprapubic. Deep pulpation: I am going to apply more pressure – there is no guarding in deep pulpation, there are no obvious masses. Now I am going to feel your kidneys – there is no enlargement of your kidneys. Now I am going to do some special tests.

Murphy sign Rebound tenderness. McBurny sign. Rovsing sign.

Psoas sign. Obturator sign.

“Please sit up. Now I am going to tap your back. There is no tenderness on costo-vertebral angle. Now listening again to the base of the lungs. There is no crepitus at the base of the lungs.”

“I’d like to finish my exam by doing pelvic exam, vaginal exam for bleeding or discharge or bimanual examinations. Looking for any cervical motion tenderness, and adnexal masses.” “In DRE looking for any bleeding or haemorrhoids.”

Acute on chronic abdomen (like Crohn’s Dis.) Add to the above:

General inspection: moon faces, truncal obesity, redness in sclera, nails – pitting and clubbing, no skin rushes, no striae, no erythema nodosum on legs, sacroiliac joints look normal.

 

Acute Abdomen, Physical exam



Intro General inspection: the patient is lying comfortably and I see no signs of distress. Can I get the vitals please?

The patient is stable, normal temperature, BP, RR and HR. You are going to face – can I take a look at your eyes: there is no jaundice, no sign of anemia. Please open your mouth – there is no sign of dehydration and obvious ulcer in the mouth. Upper extremity: capillary refill is normal.

Abdomen (drape appropriately): please move the cover – by inspection: the abdomen is not distended, umbilical inverted, abdominal moves with breathing, no scars, no bruises. Ask patient to look aside and cough twice (once look at his face to see for cough tenderness and then for abdominal bulging). Now I am going to listen (warm the sthetoscope): “Normal bowel sounds, no bruits – aorta, renal, and iliac.”

Percussion: I am going to tap – show me where it pains. First tap away from painful area, than tap over the 9 areas – the painful area last. Pulpation: I am going to feel – no tender in epigastric/Rt. And Lt. Hypochondral/Rt. And Lt. Iliac regions/ Umbilical / Suprapubic. Deep palpation: I am going to apply more pressure – there is no guarding in deep palpation, there are no obvious masses. Now I am going to feel your kidneys – there is no enlargement of your kidneys. Now I am going to do some special tests.

Murphy sign Rebound tenderness. McBurny sign. Rovsing sign. Psoas sign.

Obturator sign. “Please sit up. Now I am going to tap your back. There is no tenderness on costo-vertebral angle. Now listening again to the base of the lungs. There is no crepitus at the base of the lungs.”

“I’d like to finish my exam by doing pelvic exam, vaginal exam for bleeding or discharge or bimanual examinations. Looking for any cervical motion tenderness, and adnexal masses.” “In DRE looking for any bleeding or haemorrhoids.”

Acute on chronic abdomen (like Crohn’s Dis.) Add to the above:

General inspection: moon faces, truncal obesity, redness in sclera, nails – pitting and clubbing, no skin rushes, no striae, no erythema nodosum on legs, sacroiliac joints look normal. Back to Content Hematemesis “Because it is hematemesis I’d like to initiate a ATLS protocol for me and my team, please can I can get gloves, goggles, masks, and gowns.” Intro How do you feel right now? I want to make sure you are stable and therefore I’ll give some orders to the nurse. Once you are stable I’ll ask you some questions.

ABCD

Vitals OCD + COCA How did it start? Forceful and retching? Did you vomit once or more? How much? Dark /bright blood?

Any clots? Any smell? IMPACT±PAIN -PAIN  Liver

+PAIN  GIT If No Pain: Hx: Any Hx of liver disease? Any screening for liver disease? Any bruising in body? Increase in abdominal size lately?

Alcohol: how long? How much? Hx of PUD Heartburn Any nausea When was your last bowel movement? Colour? Any tarry stool/fresh blood? Any Hx of bleeding disorder? Any NSAIDs (Aspirin) – how much? How long? Why? Who prescribed? Any blood thinner? CSx (Ask for weight loss)

Long term disease Physical exam:

Vitals If suspected liver disease (no pain): Sclera – no yellow discoloration, pallor Enlargement of parotid glands

Mouth: Fetor hepaticus, mouth is clear no bleeding no clots Hands: no clubbing, capillary refill, no atrophy of thenar or hypothenar, no palmar erythema, no dupytren’s contraction, no flapping tremor Chest: no spider nevi, no gynecomastia, normal chest hair, no bruising Abdomen: not distanded, umbilicus normal, caput medusa, collateral veins, no bruising. Auscultation: bowel sounds normal, bruits (aorta, renal, iliac), no hepatic rub, hum, or bruit; No splenic rub, hum Tapping: four taps – general percussion, percussion for liver (upper and lower margin), spleen (Castle sign), shifting dullness DRE Testicular atrophy Peripheral edema Epigastric tenderness

Gastroenterologist consult and admit to ICU Endoscopy and IV PPI

Acute Abdomen – management



Abdominal pain 24 hr with vomiting and diarrhea, BP 90/60, Pulse 140 Diagnosis: acute pancreatitis

Intro: “As I understand... please bear with me, as your BP is low I’ll give orders to the nurse, and as soon as you become stable, I’ll give you something to relieve your pain.” A B– Vitals, Oxygen saturation C– because he is hypotensive and tachycardic you give IV fluids; Take blood to: (add amylase to the other blood work) D– Gross neurological exam Hx What happened?

Pain: OCD, PQRST, AA Vomiting: how much, how many times, amount, forceful, blood/coffee ground IMPACT RF (Alcohol, Gall stones, Hypertriglyceridemia, DM, Viral infection, Medications) Recent trauma Alcohol: how much, when was last time, last drink (was it more than normal?) Hx of gall bladder disease Recent flu DM Medications CSx

Hx of HTn (R/O Aortic dissection) Chest pain Cough, phlegm Flank pain Liver disease PMHx FHx SHx

Vitals 2min stabilize, 4min Hx

P/E Look for liver disease: sclera, tongue, and hands Abdomen: Drape No Cullens and Great Turner signs. Look for cough tenderness. Auscultate bowel sounds: no aortic/renal bruit. Feel or tap abdomen Groing exam DRE Orders: Meperidine, NPO, NG Tube, Admit to ICU, Foley catheter, Input-output chart, Imaging: AXR, Abdominal U/S and CT, surgical consult  

MI – Management



Hx OCD

PQRST (if it is suspected to be ACS - stop at R and start primary survey) Primary Survey (If patient talks – Airway preserved, Take Oxygen saturation and start Oxygen Stat – 4L/m through nasal prongs) VITALS: Auscultation: •Air entry (N) •S1 & S2 (N)

IV lines : NaCl 50ml/hr to keep line open, from the other side take blood for: Troponin, CK-MB, Cr, BUN, Lytes, CBC, INR, PTT, LFT, Toxic.,

Alcohol, Lipids; and finger prick for Glucose) ECG 12 leads & continous monitoring Portable X-ray (r/o dissection)

Ask about Allergy for Aspirin and Viagra (if negative)[12hrs for Viagra & 36 hrs for Cialis] Give ASA chewable (325mg) Non-ST elevation

Nitro x3 (S.L) Morphine Continue now with: PQRST AA&A How do you feel now? Ask Hx: CVS GI (especially peptic ulcer) CSx

RS DVT ST Elevation: do not go for DDx Nitro (IV Nitro is C/I in IWMI) Morphine (5mg if ALMI, and 1mg if PWMI) VITALS: (again)

R/O Contra Indications for Thrombolytics: •Peptic ulcer & Recent surgery, •Pericarditis, Aortic dissection, •Brain tumor, & Stroke Start Thrombolytics:

Tpa

•Ask for heparin protocol •Start B Blocker RISK FACTORS: • HTN •DM •FH

•Coccaine Nitro (2nd dose) O/E: •JVP •Listen to heart •Base of lung

•Compare BP in both Upper extremities to r/o coarctation of Ao CXR Once there is no Aortic Dissection  Thrombolytics (should be clear to r/o: Peptic ulcer, recent surgery, pericarditis, aortic dissection, brain tumor, and stroke) Based on ECG – counselling

Counseling

Based on your ECG it is most likely you are having an heart attack. If stable – BP and HR are stable, but it is a serious condition, however it is treatable. Heart attack means that greater than one blood vessel supporting your heart is blocked by a clot that has to be reimoved. The medications are called clot busters. Based on ECG and no sign of pericarditis or signs of aortic dissection you are a good candidate for treatment. It is an effective medication, needs consent. 1% chance of stroke and we can start heparin.

Respiratory System – P/E



•General inspection: comfort, colour, pursed lips, flare nose, intercostal retractions, auxiliary muscles

•Eyes, nose (perforated septum), mouth (ulcers, thrush in HIV, central cyanosis, moist tongue) •Hands: peripheral cyanosis, clubbing, capillary refill •Cervix: trachea, lymph nodes •Chest: inspection (symmetry, expansion, intercostals retractions); Palpations for any pains, estimating chest expansion Tactile phremitus (“99”) Tappings (including sides): dullness/tympanic, diaphragmatic excursion Auscultation (including sides): vesicular sounds Vocal phremitus: “E” Whispering pectoriloqui: “1,2,3”

•Heart: pulses and auscultation (r/o AF and Rheumatic disease). •Other lymph nodes: axial, femoral, popliteal •Lower leg: no signs of Caposi sarcoma, DVT (Homan sign, measuring calf in case of tenderness or suspicious calf swelling).  

Diabetic Daughter 2y, Counsel



Either she is not doing well in school as she is not seeing well due to vision problems Not playing well, as she is tired DKA

Is it regular f/u or something special you wanted to discuss? When was the last f/u? How was she diagnosed?

What happen then? What were the symptoms? Any pain / vomiting? Are you feeling eating/drinking/peeing more? Any weight loss or blurred vision? From the last f/u till now have you had DKA?

How about before? Have you had low blood sugar? Talk with the father: Which medication does she take? How does she take?

When was the last time? Do you take insulin or somebody else gave it to you? Do you take it all the time? DO you skip dose? Does she need any help to take insulin? DO you measure blood sugar regularly? When was the last time?

Do you record them in the machine? (The glucometer should be used by only one patient). There is a blood work called ―Hemoglobin A1C‖ it is done every three month – did you do it? Did you start new medication?

How about your diet? DO you have your log book? What do you eat? Have you ever seen by a dietician? PMHx FHx

Counseling A lot of people have diabetes and she is not the only one. What’s your understanding of diabetes?

Whenever we eat food contains sugar it is absorbed in our stomach and goes to the blood and from there to different parts of our body. Sugar act in our body like a fuel, in order for our body to use this energy it needs insulin. Patients having diabetes have not enough insulin. Sugar will be built up in your blood. The body tries to get rid or it, by peeing extra sugar – this will lead to thirsty and tiredness.

This can be avoided by controlling the blood sugar. If you control your blood sugar you’ll be able to play again. If not controlled – may end in DKA, hypoglycaemia and serious consequences. Always be aware of hypoglycaemic symptoms: loss of conscious, sweating, heart racing, hungry. Since you might lose conscious it is important to carry MedAlert Caed or Bracelet which will clarify your situation.

  Medical Error, Wrong blood transfused



When there is a mistake, always there is a kind of unintentional medical error. (to the nurse) when informed about wrong blood – ask: ―did you stop the blood?‖ say: ―Well done!‖ If she asks not to tell the patient...ask her what her believe she may lose her job, and it is too early to determine who is responsible. Errors take place in medical practice. We don’t know what exactly

happened. We will stabilize patient and ensure he’s fine and later deal with this issue. Remove blood unit and keep cannula (to the patient)INTRO:

I am the doctor in charge, and it looks like it was an unintentional medical error took place. We need to make sure you are stable. We don’t know who is responsible, there are at least 15 steps and in each step could have been an error. We will fill an incident report and as soon as we get result we will inform you. You can sue, it is your right at the moment it is my priority to stabilize you.

I will start PRIMARY SURVEY:,

ABCD A – Open your mouth (check for anaphylaxis, no swelling in mouth, ask for any itchiness, or difficulty breathing), Oxygen saturation.

Normal air entry. Normal S1, S2 VITALS: Pleaese . Remove blood unit and keep cannula C: Start new IV line.

Once new line, don’t give fluids if stable. Send blood: CBC, Lytes, INR, PTT, LFT, Cr, BUN, FDP, Haptoglobulin, Direct coombs test; Urinalysis: hemoglobulinuria Unit to be sent to blood bank for cross matching. Ask nurse to call the blood bank and keep original blood. D D1 – I’d like to shine a light in your eyes. Pupils are round, active, and symmetrical. Squeeze my finger, wriggle...wriggle... D2 – (if febrile) give tylenol Please prepare for me : •Benadryl (Diphenhydramine) 50mg. •Steroids (Hydrocortisone) and •Epinephrine SECONDARY SURVEY: Hx (two parts:) 1.Condition (how is he feeling now) 2.―Why blood was given?‖

CONDITION:

Check out for Anaphylactic shock: Do you feel warm? Chills? Itchiness? Tinglings? Diffculty breathing? Wheezing? Swelling in lips / fingers? Hives? Before transfusion did you have fever? Check for Haemolytic reaction – any back or flank pain? P/E – no oozing at IV line Then press on flank and back – no pain for haemolytic reaction. Is it the first time? WHY did you receive blood? If received blood before – was there any complications? Any long term diseases? COUNSELLING:

Mr. X what do you know about blood transfusion? It is a life saving measure, and a lot of measures are taken to make sure it is safe. However, like any other medication with blood transfusion there could be side effects, and these side effects could be serious.

The most common side effect is: •Febrile reaction (3%), usually it is self limited and can happen again. Next time you receive blood we will give you tylenol.

•Anaphylactic reaction. It is a severe allergic reaction, and it is very serious and we cannot predict it. However, we have good measures to deal with it, and your symptoms make it less likely that you have had an anaphylactic reaction. The third reaction is more serious and called •HEMOLYTIC reaction. Usually happens when patients receive blood belonging to another blood group.

The fact that this blood is same as your blood group, and the symptoms are not consistent with haemolytic anemia make it less likely that this is not the case here. The blood is sent to the blood bank and once results are back we will get final confirmation, we will able to reassure you.

Son has anaphylactic shock, is stable now.



Next few minutes I’ll talk with you and hopefully will come to a good plan.

Yawning – give empathy. Hx (Short)

It happened at home you should take history.

If not – don’t take history.

•Itchiness, • Swelling, • Hives.

•Was he able to talk, wheezing, chest tightness, • Lost his consciousness, • Turned blue?

Start immediately with Epinephrine.

What have you done at the event? What did they do?

Any other children at home with anaphylactic shock?



Management Based on the Hx your child has anaphylactic shock.

Explain: a kind of severe allergic or hypersensitivity, from birth or develop later. Usually people get allergic to foods, medications, or chemicals.

Any questions?

At certain stage the immune system starts to interact with some elements of the peanut which are called antigens. From now on when your son will be exposed to the same antigens it will lead to release of some chemicals which will affect his skin, widening blood vessels which will become leaky and different parts of your body will become swollen.

When not enough blood will reach the brain it will lose conscious, difficulty breathing. The concern we have is that it might happen again. It is common.

Plan: the best treatment is prevention.

After that I need to go and talk with your child.

•You have to check the ingredients of any food you buy – make sure it is peanut free. •IF there are other children at home they must be informed as well.

•In case that your child was exposed to peanuts by mistake, you should use EpiPen – this is a special pen, has a cap at the top, which is needed to be activated by removing the cap, press it against his thigh for ten seconds. This increases the blood pressure for about 20 min, in that time you should seek help.

•Your son should carry with him two pens – one at home and one on his bag. • he should carry Med Alert. In case your child become unconscious • I will refer him to allergist specialist. •Aspirin, stress test, and imaging...

•Some children will outgrow it.

Marijuana Counselling



(Mother comes in to see you as she has discovered Marijuana in her son’s belongings)

INTRO:

As I understand you’re here because you’re concerned about your son.

What is his name?

What is your concern?

How much did you find?

Did you ask him about it?

•WHAT MAKES YOU BELEIVE IT IS MJ ?

Is he using it? Or Is he carrying it?

Is it the first time you’ve found it?

•Did you notice any CHANGES in his behaviour?

Is he excited?

Laughing out of nowhere?

Is he preoccupied?

Does he stare at a wall?

Does he talk to himself?

Is he aggressive?

Any problems with the law?

Any fights?

Any criminal records?

Is he more isolated?

•How is his MEMORY?

Is he more forgetful/lose his stuff?

Does he take more time to react?

Does he spend more time in his room?

How much time do you spend with him?

How much time is he out of the home?

How much time does he spend with his friends?

Do you know any of his friends?

What kind of activity are they involved in?

•Does he have a lot of MONEY?

Does he ask for money?

Do you believe he steals money?

Do you think he smokes/or drinks alcohol?

•How would you describe his MOOD?

Is he depressed?

Is he still interested in his hobbies?

Does he worry a lot?

Does he have excessive fears & avoid situations?

Do you have concerns that he may harm himself or anyone else?

EDUCATION:

How is he doing in school?

Have his grades dropped?

DIET:

How is his general health?

Have you ever seen a psychiatrist? Fhx: SAD COUNSELLING:

Based on what you’ve told me.There are no changes in his health & behaviour (assumed that there were no changes in behaviour as per mum) When it comes to Marijuana it is a commonly used drug by teenagers, sometimes only once for experiment. When we talk about Substance Abuse & drugs we talk about different categories. Marijuana is a SOFT DRUG,others like: Coccaine,Heroin& Amphetmanies are HARD DRUGS Let us talk about Marijuana first.

It is from the Cannabis family & affects the brain by feeling happy, excited & enhances experience.Sometimes with prolonged use or in high doses can cause side effects including apathy.

It interferes with memory,& can interfere with his studies & function & fine motor skills & may not be able to operate machinery It impairs judgement & he might take risks. Can cause Lung cancer

In some teens,in high doses unmasks schizophrenia & cause psychosis Interferes with sexual function & can cause infertility & weight gain

By itself marijuana is not strongly addictive & hence he can stop it at any time with help.One of the concerns of Marijuana though is it acts as a bridge to Hard drugs which are addictive i.e you’ve to increase the dose to have the same effect,which is called “TOLERANCE”,& then one cannot stop the drug as it causes withdrawal .

It is a crime to use,hold hard drugs.People can lose their jobs.

If injected increases risk of HIV,Hepa B & C

PLAN

If you like,bring your son here I can talk to him.

It is better to be a confidante to him. Try to be close to him, someone he can trust & can talk to.Try to make sure who’re his friends,& make sure you know what he is doing.Keep him busy with activities.

If there are any druh prevention programmes in your community or his school,get him to attend them & gets the knowledge.

In case of the resident who was asked to backup his supervisor orthopaed

7.I am competent – to emphasize

8.Short term – we don’t have time so we need to see her urgently

9.Long term – solve the situations that it wouldn’t occur again

Pregnant 35 YO has concern about breast feeding.



Tell me more about your concern.

Is it: General information you like to discuss or some specific concerns?

If worried about pain: Ask:

Have you ever been pregnant before?

Have you ever breast fed before?

What makes you believe it is painful?

In addition to that any other concern?

Mostly my concern is...

It is a good concern,& I’m gald you came in today.

How is your pregnancy?

When was your last F/U?

When is your due date?

Let us talk about the pain.....

Breast feeding is a natural physiological process & usually it does not cause any pain.

However, sometimes it might cause some discomfort.

If it pains there should be some reason for that.

Most of those causes are treatable

Most commonly – cracks and fissures. They are caused because of not proper care of the nipple.

You have to make sure that they are moist, clean them, and don’t use soap.

To learn appropriate technique it might take some time.

I can send you to some classes that might guide you.

Retracted nipple and inflammation of the breast (mastitis) you can still continue to breast. Localized condition, like abscess, we still recommend to continue to feed breast from the other side. Before we proceed further I’d like to make sure if you are a good candidate for breast feeding.

Do you have any long term diseases,

Do you take any medication or radiation,  Do you smoke or taking any drugs, Have you been screened for TB or HIV.

Do you plan chemotherapy or radiation therapy?

Based on what you’ve told me,you’re a good candidate for Breast feeding COMPARE BETWEEN BREAST MILK & FORMULA

The reason we recommend breast feeding is that we cannot match it with formulas. The first 24 hours secretion is “ Colostrum” ,it is a special kind of milk& has a lot of antibiotics, immunoglobulin & essential amino acids, which are essential for your baby which will give him protection.

With time the milk becomes more mature and suits the needs of your baby. It has the right amount of carbohydrate & fat. The quality of the fat is better. It has more whey relative to casein. The iron is less than cow milk but is more available (50% as to 20%).

Less load on the kidneys

There are other benefits to your baby and you – there is emotional connection which is important to both of you.

Babies breast fed have

•Less chances of having allergies

•Less chance of having diarrhea

•Less chance of being obese

•Less ear infection,

•Some studies even suggest that they might have higher IQ.

There are some benefits for you (the mom)

It helps to lessen the postpartum bleedings (because the oxytocin) the uterus go back to it’s size Helps you to regain the figure you’d prior to pregnancy. It is clean, available, always at the right temperature, even though you don’t pay for it – It is one of the most important things you can give your child. If chooses to breast feed:

I will send you to clinic who will teach you.

At the beginning the breast feeding is on demand & with time it regulates ,& you need to feed every 3 – 4 hours & at least 10 min in each breast.

Monitor weight gain to ensure that the baby is adequately fed. Occasionally the baby may be jaundiced & sometimes stool may be loose. If you choose to breast feed you’ve to be careful whenever you take medications or alcohol.

You can go back to work, after the Maternity Leave (ask for how long) Breast feeding can be continued. You can use some special pumps. Even if there is engorgement you can use the pump. Make sure it is always clean. Breast milk can be stored at 6hr in room temp, 24 hr in fridge, and 6m in freezer. Don’t put it in the microwave for heating.

Breast feeding is not reliable method of contraception. Recommend the minipill or barrier method.

Febrile Seizure

A child brought to the ER because of febrile seizure.Next 10m counsel him.

EVENT

TRIGGER r/o meningitis.

EDUCATE & what to do next time INTRO:

As I understand you’re here because your child had a seizure 20 minutes ago,& my colleagues are looking after him & he is stable. During the next few minutes I’ll ask you few questions, and after that I’ll go with you to see him.

EVENT:

•Describe the event.

•What happened?

•Did you see him? (Started to shake. All over his body? Bite his tongue / rolling up his eyes / wet himself).

•Did he fall from a height?

•How long did it last?

•Did he stop seizing by himself or did he need medical intervention? •How did he regain consciousness?

After the seizure does he have any neurologic deficits: •Was he drowsy

•Did not recognize you

•Able to move his arms & legs Is it the 1st time? Or happened before If first time:

Ask about fever?

(if it started a week ago – did you seek medical assistance? Any ear discharge? Did they give you any treatment? Did you give it to him or no?)

Why! Some studies show you can treat OM without antibiotics. If reason medication not given was because parent was busy.....You should look for the reason not to give the antibiotics (negligence?). Was he playful,eating,drowsy,

Is he having any vomiting?

Skin rash?

Coughing & phlegm SOB, Wheezing Foul smelling urine & painful peeing Head to toe...

If you find nothing – ask when he got his last shot? (up to 72 hours he can have fever). •R/O meningitis, pneumonia.

•Any family history of febrile seizures, epilepsy BINDE (especially immunization to R/o Measles)

COUNSELLING:

Most likely on what you’ve told me, your child has condition called febrile seizure (FS).Do you know what it is?

It is a special condition in children that might happen from 6m to 60m. We don’t know exactly why – we believe it is a sudden change in the temp & as the brain is not developed fully thes e changes might lead to the seizure. This condition might happen again. The best treatment is:

PREVENTION

Therefore from now whenever your child has a temperature Seek medical attention. Give Tylenol and sponge bath to decrease his temp.

Most of the children will outgrow this condition by the 6th year.

Chances of epilepsy later in life are higher

In FHx of epilepsy,it is a risk fct for development of epilepsy.

They don’t recommend Diazepam because it might make him drowsy. I will give you brochures

If it stopped less than 5m or more than 5m including neurological symptoms seek ER immediately. Brochure.

 

  PHONE CASE:

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“This is Dr. ... (immediately should introduce yourself). I am the Dr. In charge in the ER.As I understand, you’re calling as your child has swallowed some medication. I know that you’re stressed & it is a difficult time for you. I need your phone number now & it is important, as if we get disconnected I will call you back.

What is your address?

How far away from the hospital are you?

Try & stay calm. Your son needs you, I am going to give you some instructions and you need to follow them.

FIRST STEP:

Is your son is alert or not?

Is he conscious?

Can he talk to you?

Can he recognize you? (If he doesn’t – do you know how to do CPR and start with that.) He’s crying?

What is his colour? Pink?

Hold him and try to calm & soothe him.

Try to hold him and check his mouth,if there are medications there,remove them.

Is he breathing?

We’ll send the ambulance for you.

When did it happen?

How long was he alone?

Which medications did he take? Whose medications did he take?

Do you have the container?

(Don’t go to the next room to bring them,when the paramedics arrive then you can go & get the container).

Do you know what condition your father have (was it vitamins, sleeping pills, or any other?) How much the amount?

Don’t use any ipecac? Do not induce vomiting.

Is it happened before?

What is the weight of the child?

BINDE (was it full date, did he needed special attention after term, and does he have any special conditions). Weight for two reasons – antidote and estimate neglect.

Are his shots up to date?

Are there other children at home?

Have you visited the Er frequently?

Post encounter Q: what are the first four steps you do when he arrives?

ABC,

Monitor vitals,

IV line, NG,

Foley as needed,

Blood works – CBC, Lytes, BUN, Cr, Osmolality, Coagul, LFTs, Tox screen – blood and urine).

List three risk factors forneglect for this child.

What is the antidote for betablocker (glucagon) and for CaChannel is (Calcium gluconate). CAS & Poisoning centre.

Second scenario Phone case: Febrile Seizure

This is Dr. ... (immediately should introduce yourself). I am the Dr. In charge in the ER.As I understand, you’re calling as your childis having a seizure. I know that you’re stressed & it is a difficult time for you. I need your phone number now & it is important, as if we get disconnected I will call you back.

What is your address?

How far away from the hospital are you?

Try & stay calm. Your son needs you, I am going to give you some instructions and you need to follow them.

While he is seizing just put him on the side, and not start any CPR. Is he seizing right now? Try to put him on the floor on the left side (the right bronchus is shorter than the lt.).

Observe him.

What is his colour?

Is he still shaking? You send the ambulance.

Can you tap on his shoulder?

If he is not responding – can you do CPR?

Can you feel his pulse? If stopped seizing...... Good Is he alert? Does he respond?

Can he talk to you?

Can he move his legs?

EVENT:

Can you describe what happened?

OCD

Fever +/-

Does your child have fever?

Did he have Hx/Nx/Vx/Skin rash/Neck stiffness Any long term disease?

Did you seek medical attention? What prevented you from giving the medication?

Is it the same time or happened before. If it is the second time – more than 15m he needs intervention.

Post Concussion



Hx & PE

INTRO:

As I understand you had a head injury 3 days ago when playing hockey. Start with EVENT: Before & After If LOC ask How long?

Do u remember what happened? What was done?Were you hospitalized?

Was a CT Scan done?

HOW DO YOU FEEL TODAY? Full neuro assessment Headache:

OCD PQRST U V A&A

Vomiting,bending,Nausea

Balance,vision falls weakness numbness Difficulty finding words Past Med Hx:

HEADDS

PE:

Vitals

CN

Power

Reflexes

Sensory

GAIT check Tendem gait

Conclusion:

I know you’re eager to play hockey

Since you’ve headache you’re not ready to play again as you still have active Sx. If you start to play again your tolerance for injury is lower & if you are injured again,your tolerance is lower & recovery time is longer & there might be serious consequences. Why don’t you wait till full recovery time

I will refer you to a PT & with gradual step up exercises you can get back to your game: One week with warming up, after that stationary activity, after that skiing, than drilling without contact (seven steps of rehab.).

Osgood Schlatter

2 scenarios (Osgood schlatter and Post-concussion)

Decision will based whether the child can tolerate pain or not?

#1 About to see the father of 14yom with Osgood Schlatter.

Make sure that the child best interest are preserved. What was done to diagnose the child?

OCD PQRST compare to the other knee, is the first time or not, was any trauma. What is the child wish? (Don’t go for HEADDSSS since it is the father).

Counseling

What is your understanding of OS.

Let me explain to you what is the mechanism for OS.

Avoid him from playing, especially jumping. But he can continue with ice presses and pain killers. The rule is that he can continue up to his limit of his pain.

  IMMUNIZATION

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(Newcomer come to Canada from Ukraine, concerned about immunization) May need interpreter: Ask:

Do you understand?

Can I talk slower?

Do you need interpreter?

INTRO: As I understand you’re here as you’re concerned about vaccines & my understanding is that you’re new to Canada, Welcome to Canada!

What is your concern?

•Pt: My neighbour told me vaccines are not safe Dr: what do you mean?

Pt: Concerned about autism & vaccine

Dr: This is a reasonable enough concern,& I’m glad you came here.

There is a misinformation about between vaccines & autism.The origin of this misunderstanding is due to a study done in the UK & the author of that study found a connection between autism & vaccines. Because vaccines are lifesaving & important for our children’s protection,further studies were done,also in other countries,& then it was definitely proved that there is no connection between autism & vaccines.The only connection was coincidence between time of the vaccine & time when symptoms of autism were picked up by parents.

•Another common concern is that mercury was used as a preservative for MMR vaccine. It is no longer used now.

When we find out why this study gave such a result it was found out that there was a bias in sample & thus led to the wrong conclusion.

•Another common Qn pt may ask:

These diseases do not exist in Canada, so why give my child the vaccine if there is no disease here.

The world is getting smaller & even though we do not have these diseases in Canada, because we have the vaccines, it does exist around the world & people travel.So we do not want your son to get affected whenever there is an outbreak somewhere in the world.

Hx: Let me ask some questions about your son:

•How old is he?

•Has he received any vaccines so far?

•Were there any side effects?

•Any reason why he was not vaccinated?

•Does he have any congenital medical condition? • Does he have any allergies (egg??)

• Any neurological history?

Inform that baby is a good candidate

As I told you vaccines are life saving, before vaccines many children died from measles, rubella. The reason being children are not fully protected & may get the infection & die. Once vaccinated, children get the immunity Any Qns?

HOW:

We take different bugs like bacteria, viruses or products of these bugs & process them so that it does not harm the body,& inject it into our bodies by needles. Our body reacts by forming elements that fight these antigens, so later in life when your son is exposed to the real factor, these antibodies will protect him. Some of these antibodies will last forever; some will need booster doses.Because there are a lot of disease we need to minimize the number of injections & we’ve to give greater than one needle for vaccination. There is a combination vaccine e.g: PEDISIL = DPT + HiB + Polio This is given as a single shot at 2,4,6 & 18 Mo.

We will give you a schedule to remind you each time you’ve to come to the clinic Concerning the SIDE Effects, the benefits clearly outweigh the S/E,however: A febrile reaction can develop & you can give Tylenol if this occurs Pain & swelling at injection site

Some children can have prolonged crying

Others may become floppy

In still rare conditions can have a seizure

Very rarely,can gt an anaphylactic reaction

Since you’re a newcomer & not got your insuarence there are some organizations that will help you out.

IUGR



INTRO:

As I understand you’ve just given birth to a baby,& my colleagues are looking after

him,& I’m here to talk to you.

How do you feel right now?

Have you seen your baby?

Did anyone tell you about your baby?

If at this point mother voices a concern that she saw her baby covered with green stuff. Your baby was covered with “Meconium” one of the substances in the fluid surrounding your baby.It is normal for the baby when under stress during delivery. I’ve been told that your baby has a condition called “IUGR”,& I need to ask questions as to why it happened Qns about Pregnancy: Smoked/Alcohol/Drugs Qns about Delivery:

Term or preterm MGOS:

O:Previous pregnancy/abortions/miscarriage, & if yes how many?

G:If Hx of Cancer or chemotherapy

Any congenital disease in her or husband’s family or Consanguinity If she asks whether her mistake:

Don’t reproach her – it is NOT her mistake.

It is a multi-factorial condition. Can be due to various causes, some genetic, pregnancy, related to baby

Because safe levels of smoking, drugs & alcohol not known, We always recommend not to smoke or drink for future pregnancies.

CHILD ABUSE:

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•# Femur

•# LE & (B) limbs

•Spiral #

•# post ribs

1.EVENT

2.1st time or prior

3.BINDE:

4.Past MH for osteoporosis imperfecta

4. COUNSELLING

INTRO:

As I understand you’re here as your child had a #.My colleagues are looking after the child, who is stable now.

EVENT:

How?......Describe what happened….if fall from couch: How high is the couch? When? …If time log……Why bring the child now??? If at night? Did he sleep or was he crying?

Were you there?

Did you see it?

Any LOC?

Is it the 1st TIME or has it happened before?

If before?

How many times?

Type of #?

Did you come to the same hospital or to a different one?

Any other children at home?

BINDE:

Planned pregnancy

Term pregnancy

Any cong anomalies

During pregnancy: SAD

Immunizations up to date or not

Weight today

Development: Is he a difficult child?

Environment:

PARENT-CHILD RELATIONSHIP:

Stress at home

Who is primary caregiver or who feeds the child?

How do the parents punish the child?

Financial problems

SAD

Any Psy Hx in either parent PAST MH:

Here specifically ask about Osteogenesis Imperfecta

Counselling

I can see that you’re going through a difficult time. Sometimes it is challenging to work & care for a child. From the history you gave me about the injury is not enough to explain such an injury. Children at this age have very flexible bones which are difficult to break by jumping off the couch. I’m sure you share my concerns with me about the safety of your child & in this situation we contact the CAS. The CAS will come & ask questions & talk to you & your partner:

If does not accept & says will take my child…….

Ask what makes you think like that? Do you have any experience about these matters? It is not neccassarily,they will asses the situation & if the family is considered safe… If pleads etc: Tell I’ve a legal responsibility to report to the CAS



  SUICIDE ATTEMPT 16/F suicide attempt ASA overdose

Sex:

AGe

Depression

Previous attempts

Ethanol use

Rational thinking loss

Suicide in family

Organized plan

No support (here put HEADSS)

Serious illness

INTRO:

As I understand,you’re here because you overdosed on Aspirin last night & I’ve been told that you’ve been seen by my colleagues.My understanding is that you’re stable now,& I can talk to you.

HOW DO YOU FEEL RIGHT NOW?

(if she is playing around with phone etc ask her to disconnect & speak to you) Can you tell me more about what happened?

Pt: I went home & took Aspirin Dr; why?

Pt: I was frustrated Dr: Why?

I can see that you’re busy with your phone,is it important?

Can you stop for a few minutes?

I’d Like you to know that whatever you tell me is confidential here

Give confidientiality Dr: Why are you angry? Pt:I made a car accident When?

Were you alone,or with someone else?

Were you driver or passenger?

Was anyone else hurt?

How Much aspirin?

Did you talke aspirin alongwith any other medication?

Did you lose consciousness?

Who called for help?

Did You seek help ort someone else did?

Was it IMPULSIVE or PLANNED?

Did you leave a note?

Have you recently been giving away your belongings to others?

Is it the First time?

Any suicidal attempt in the family?

Do you usually take alcohol,or take drugs?

R What did you think about ending your life?

R/O Psychosis:

Sometimes when people want to end their lives they see a vision or hear voices,did you experience any of such?
 

39 YOF Pregnancy. Counseling. 10m



Hx=4mins

Counselling = 6mins

35yo – 1:180 (congenital) – half of them Down synd (1:360)

45yo – 1:45 (congenital) – 1:20 Down (5%)

•Always ask about concerns

•Why worried about Down’s

Take Hx: Age/FH/Ca/Cxt/RXT/Medications

M: LMP + Sx of pregnancy +Pregnancy test G

O: Imp

S

Past MH: Risk Fcts

FH: Congenital

EDUCATION:

CVS Amniocenthesis

Accuracy Age

S/E:

Results:

Risk of abortion: 97%

10-11 wks

Limb defec

ts 48 hrs

2%

-- 99.9%

14-16 wks

-- 2 weeks

0.5%

Checks for other conditions



INTRO: As I understand you came here today, because you found out you were pregnant last night & have requested an urgent meeting with me. What is the reason? Not ask if it is planned or not.

Ask if was on any contraception.

Confirm pregnancy by exact date.

What do you feel about the pregnancy?

What is your concern?

If she says it is her age or concern about Down;s Ask: Any experience with Down’s syndrome?

Any Fhx of congenital anomalies?

It is a reasonable enough concern & I’m glad that you’re here. There are some

measures we can take to screen for some deformities, yet it is not 100%

How do you know you’re pregnant?

When did you find out?

LMP

Sx of pregnancy: Nausea/Vx/Breast tenderness/Inc visits to wash room to pee.

Prev pg?

Any contraception?

PAP’s smear?

STIs?

FH of Cystic fibrosis

Did you discuss this with the father of the baby?

Any reason why not?

Past MH:

Medications

Chemotherapy

Radiotherapy Smoke/Alcohol/Drugs

COUNSELLING

If wants abortion,shift to abortion.There are some important figures you need to know Most of the time we’re concerned about Down;s SyndromeUsually the risk of having a child with congenital. Abnormality at the age of 35 is around 1:180 and half of these children are DS.

To r/o we do a test called amniocentesis, and the reason we offer it is because the risk of complications of miscarriage is lower than the risk of congenital abnormality. 0.5% (abortion) compared to 0.55% for DS.

If not willing then go to amniocentesis.

We can arrange for it. First we confirm pregnancy by US to get the exact date. Then insert a fine needle guided by US into the womb & take sample of the fluid surrounding your baby and send it to the lab. Usually we do it around 14-16w and the results will come around 2w later. It is very accurate >99%. Help us to r/o other conditions is very safe. Like neural tube defects Risk of abortion is very low < 5%. At the age of 35 the risk of having a miscarriage due to amniocentesis complication is less than the risk of having a child with a congenital anomaly.

As always in medicine, we’ve to find a balance between risk & benefit. If pt wants an earlier test.

Another option, not commonly done is Chorio venous Sampling Here risk of abortion is 2%, & thus higher than amniocentesis.

The results are back in 48 hrs,however the chances of having a high false negative is 3% when baby is still affected Also there is a risk of limb injury

Genetic abnormalities: cystic fibrosis, thalasemia, etc. For that reason you should be referred to a genetic counselling.

From Mayo Clinic:

Amniocentesis is a procedure in which amniotic fluid is removed from the uterus for testing or treatment. Amniotic fluid is the fluid that surrounds and protects a baby during pregnancy. This fluid contains fetal cells and various chemicals produced by the baby.

With genetic amniocentesis, a sample of amniotic fluid is tested for certain abnormalities — such as Down syndrome and spina bifida. With maturity amniocentesis, a sample of amniotic fluid is tested to determine whether the baby's lungs are mature enough for birth. Occasionally, amniocentesis is used to evaluate a baby for infection or other illness. Rarely, amniocentesis is used to decrease the volume of amniotic fluid.

Although amniocentesis can provide valuable information about your baby's health, the decision to pursue invasive diagnostic testing is serious. It's important to understand the risks of amniocentesis — and be prepared for the results. Before amniocentesis, you can eat and drink as usual. Your bladder must be full before the procedure, however, so drink plenty of fluids before your appointment. Your health care provider may ask you to sign a consent form before the procedure begins. You may want to ask someone to accompany you to the appointment for emotional support or to drive you home afterward.

During the procedure

First, your health care provider will use ultrasound to determine the baby's exact location in your uterus. You'll lie on your back on an exam table and expose your abdomen. Your health care provider will apply a special gel to your abdomen and then use a small device known as an ultrasound transducer to show your baby's position on a monitor.

Next, your health care provider will clean your abdomen with an antiseptic. Generally, anesthetic isn't used. Most women report only mild discomfort during the procedure. Guided by ultrasound, your health care provider will insert a thin, hollow needle through your abdominal wall and into the uterus. A small amount of amniotic fluid will be withdrawn into a syringe, and the needle will be removed. The specific amount of amniotic fluid withdrawn depends on the number of weeks the pregnancy has progressed.

You'll need to lie still while the needle is inserted and the amniotic fluid is withdrawn. You may notice a stinging sensation when the needle enters your skin, and you may feel cramping when the needle enters your uterus. The entire procedure usually takes about an hour, although most of that time is devoted to the ultrasound exam. In most cases, the fluid sample is obtained in less than two minutes. The small amount of amniotic fluid that's removed will be replaced naturally. After the procedure

After the amniocentesis, your health care provider may use ultrasound to monitor your baby's heart rate. You may experience cramping or a small amount of vaginal bleeding immediately after the amniocentesis. Your health care provider may suggest resting after the procedure. You may want to ask someone to drive you home. You'll likely be able to resume normal activities the next day.

Meanwhile, the sample of amniotic fluid will be analyzed in a lab. For genetic amniocentesis, some results may be available within a few days. Other results may take one to two weeks. Results of maturity amniocentesis are often available within hours.

If you develop a fever after amniocentesis or if vaginal bleeding, loss of vaginal fluid or uterine cramping lasts more than few hours, contact your health care provider.

39 YOF high grade squamous endometrial ca.,

ASK HER ABOUT RISK FACTORS In Lab work you always ask Why?

And is it the first time?

SPIKE

Explain

Local symptoms

CSx

MGOS

PMHx

Plan (colposcopy)



INTRO:

...because it is the first time I want to ask you some questions so as to get a better understanding of your results.

Why? Is it the first time? When was it done?

Any reason prevented you from doing it?

What was your result at that time?

If done long ago?

Some people want to know in

―Are you the kind of person who prefers to know all the details about what is going on?

―How much information would you like me to give you about your diagnosis and treatment?

―Would you like me to give you details of what is going on or would you prefer that I just tell you about treatments I am proposing?‖ If not anxious:

What do you know about Pap smear?

Yes, we look for changes in the cervix including cervical cancer What do you know about Ca Cx?

It is a common cancer & we pick it up with Pap’s smear & if detected early, outlook is good

What are your expectations of today’s visit?

The results are back & ―I wish I had better news for you but unfortunately it shows you have some changes in the pap smears, & these changes are called ― HGSIL‖.& these changes if Ca or not are not detected by PAPs smear. We need to do further assessment to determine whether it is Ca or not.

Let me ask you some questions to see if you have some symptoms related to it:

Local, Meta, Constitutional

LOCAL: Vaginal bleeding/Discharge/Ulcers/Blisters/Warts?

Pain with intercourse Bleeding with intercourse

Lumps, bumps in groin area?

Fever,wt loss,Back pain?

MGOS

M:At which age you had your first period, G: Any Gyn surgery Contraception?

O: Have you been pregnant?

How many times?

At which age was your first pregnancy?

S: At what age were you sexually active?

How many partners did you have?

With whom do you live? How long have you been in this relationship?

Before this relationship,How many partners did you have?

STDs, Smoke,

How do you support yourself financially

Past Medical Hx

Family Hx

―I have bad news. The colposcopy result came back and consistent with cervical cancer.

We need to take further steps & I will refer you to a gynaecologist.

If you want future babies they will use local options & do something called a Cone biopsy

If you do not want any more children the uterus & cervix will be removed & the prognosis is excellent

Allergic Rhinitis, Counsel

Intro

OCD

(seasonal: caused by pollens from trees. Summer, spring, early autumn – usually last several weeks, disappears and recurs following year at the same time; Perennial: occurs intermittently for years with no pattern or may be constantly present);

P: is the nasal congestion is only in one side (allergic rhinitis) or varies from side to side (vasomotor rhinitis)

COCA-B (should be clear rhinorrhea, under microscope it contains increased eosinophils); Watery/mucoid: allergic, viral, vasomotor, CSF leak (halo sign) Mucopurulent: Bacterial, foreign body

Serosanguinous: Neoplasia

Bloody: Trauma, neoplasia, bleeding disorder, hypertension/vascular disease

ΑA: Allergic rhinitis (hay fever): most common inhaled allergans - house dust, wool, feathers, foods, tobacco, hair, mold; most common ingested allergans – wheat, eggs, milk, nuts;

Vasomotor rhinitis: caused by – temperature change, alcohol, dust, smoke, stress, anxiety, neurosis, hypothyroidism, pregnancy, menopause,

Drugs: parasympathomimetic drugs and estrogens (OCPs, HRTs);

Beware of rhinitis medicamentosa: reactive vasodilation due to prolonged use (>5 days) of nasal drops and sprays (Dristan, Otrivin)

ΑSx: Itching eyes with tearing, frontal headache and pressure, hypothyroid symptoms, change in menstruation (pregnancy/menopause);

MOAPS (especially – anxiety, neurosis, and drugs);

Complications: signs of sinusitis (pain in the face, post nasal drips, fever, severe headaches, teeth pain, PMHx of sinusitis); Ask for diagnosis of nasal polyps or obstruction in breathing through the nose when there is no sign of allergy; Ear pain (especially serous otitis media)

SHx:

Counsel:

From the Hx I’ve just taken it is most likely that you suffer from a condition called: allergic rhinitis/vasomotor rhinitis. This condition is very common and is caused by exposure to irritants in the environment which are called alergans.

These alergans trigger the immune system to release substances which cause the congestion in your nose. Finding and eliminating the appropriate trigger/s can prevent this condition.

For that reason I am sending you to do some allergy testing.

Meanwhile I can recommend several options to alleviate your symptoms.

For allergic rhinitis:

•Nasal irrigation with saline

•Spray, nasal drops, or tablets with antihistamines (e.g. diphenhydramine, fexofenadine)

•Oral decongestants (e.g. pseudoephedrine, phenylpropanolamine)

•I wouldn’t recommend to use topical decongestants since they may lead to a condition called “rhitinitis medicamentosa” which may increase and deteriorate your condition. In case of necessity – you may use a topical decongestant up to five days.

•There are many other medications that might help in case of serious condition – like steroids (fluticasone), or for prevention (disodium cromoglycate), also ipratropium bromide. If very severe oral steroids may be used.

•Desentization by allergen immunotherapy is also an option in some cases.

For vasomotor rhinitis:

•Some relief can be achieved by exercise (increased sympathetic tone)

•Drugs that called parasympathetic blockers (e.g. Atrovent nasal spray)

•In serious conditions – steroids (e.g. beclomethasone, fluticasone) •There are also some invasive procedures that might be used in stubborn cases. Surgery (which is often with limited lasting benefit), electrocautery and cryosurgery which use hot or cold instruments to affect the lining or your nose.

Overall this condition can be annoying but it is not dangerous and there are many ways to treat it. However, in most cases it is repeated and the benefit of each treatment should be well balance against its risks.

  Enuresis

Intro, ask about the concern

Ask about the name and age of the child OCD - Analyze the problem:

Since when is he wetting his bed? Is it primary or secondary?

Does the child lose control on his bladder during day or only at night?

When did the child control his bladder and toilet?

How does the child feel about it? How do his caregivers feel about it?

R/O organic causes (red flags):

DM: Drinking too much, going more often to pee, feeling tired, lost weight DI: Hx of meningitis, encephalitis (brain infection), head trauma Seizure

UTI: Dysuria, odd smell or colour of urine

Neuro: Bowel dysfunction, leg weakness or numbness, trauma or surgery to back Stress: Any stress or problem or new event

Others: Sickle cell disease, pinworms, constipation, and the most common cause for diurnal dieresis is micturition deferral

PMHx – including medications (diuretics) and allergies

FHx

BINDE (briefly – because the child is 8-9 y.o)

How was the pregnancy (any problem)

How was the delivery (NVD vs. C/S)

Term or pre-term

Are his regular shots up to date?

How is his nutrition (does he eat well balanced diet)?

How is his school performance?

Who is the primary care giver? Who else live with them at home? Is he the only child?

Counsel

•Explain what is happening – say it is m/p regression of his development because of the current stresses in his life

•It is caused by maturational lag in bladder control while asleep. It is self limiting and you need to give the child some time and he will adapt very well to the changes. About 20% of the children resolve spontaneously each year.

•The prevalence of this problem: 10% of 6 y.o, 3% of 12 y.o, 1% of 18 y.o •Treatment by changing life style: limiting nighttime fluids and voiding prior to sleep, engaging child using rewards, bladder retention exercises, scheduled toileting •You can try a method called ―conditioning‖: ―wet‖ alarm wakes child upon voiding – this method has 70% success rate

•As last resort you can try even medication: DDAVP by nasal spray or oral tablets, but there is high relapse rate and it is costly. Other medical options: oxybutynin (Ditropan), imipramine (Tofranil) – the latter is rarely used since it is lethal in overdose and has cholinergic side effects.

Important Drugs to Remember

Enuresis

Desmopresin 0.2-0.6mg at bed time

Torticulosis

Treatment: Diphenhydramine 50mg

Warfarin counselling

Enoxaperin 20mg OD (low risk)

Enoxaperin 40mg OD (high risk)

Want to stop Li

Normal level 0.5-1.2