step2 cs notes

7/25/2019 Step2 CS Notes

1/50

STEP 2 CS Cases

SOB

I can see that you are in great distress. Is there anything that I can do to make u more

comfortable?

D/D:

Acute causes- CHF, Asthma Chronic causes-CO!

"#$! %ronchiectasis

%ronchitis &%

neuomonitis 'ung ca Foreign body I'!

(orku):

C%C

C*$

eak flo+ measurement

F&sethacholine challenge test

)utum for gm stain and culture

! O # F C A A A

A-is it aggra/ated on +alking,slee)ing or resting?

F 0 1 & & & &

Associated symps: do u ha/e O% at rest? If no, ho+ far can u +alk b2f u get O%?

!o u +ake u) at night because of O%?

!o u use any )illo+s because of O%? If yes, ho+ many )illo+s?

!o u ha/e any cough? If yes-CA%CO

!o u ha/e any +hee3e, runny nose, facial )ain?-4$&I, neumonia

!o u ha/e55&% sym)s?

!o u ha/e any55.."#$! sym)s?

Are u getting your flu shots regularly?!id u tra/el recently?

!o you ha/e any55.CHF sym)s?

anic attacks-are u an6ious of anything?

Closure and advice:

It could be- infection of your chest or e6acerbation of your )re/ious condition or long standing

smoking habit or hy)ersensiti/ity of your air+ays

7


2/50

CHEST PAI

D/D:

C1- I, Angina, ericarditis, Aortic dissection

$es)- leuritis, #"I- "#$!, 4!, "astritis, !iffuse eoso)hageal s)asm

8- Costochondritis, $ib fracture, uscle strain

(orku):

#C"

C8 %, &ro)onin

C*$

C%C, electrolytes

#chocardiogra)hy

Cardiac catheri3ation

#oso)hageal )h monitoring

4))er endosco)y

C& chest for #

! O # C F C A A A

Associates symps:

C1- do u ha/e any O%?? #6cessi/e s+eating? 0ausea? +elling of your ankle or feet? $ashand 9oint )ains? $F or Co6sackie /irus;, $acing of heart, light headedness, )assed out?

!o you ha/e any "#$! sym)s?

$es)- do u ha/e any cough, +hee3e, runny nose?

!o u ha/e any )ain in your legs +hile +alking?-!1& and #


3/50

PA!PITATIOS

!!: code CHAA&I (orku):

c-caffeine serum "lucose

h-hy)oglycemia,HOC,hy)er/entilation C%C, electrolytesa-anemia &H

)-)anic attacks, )hreochromocytoma %40, creatininea-arrythmias,an6iety #C", Holter monitoring

t-thyroto6icosis

i-induced by drugs

s-stress

atient c2o funny sensation2+eird sensation in the chest or )ounding or racing of the heart

! O # C F A A

F-ho+ long does each e)isode last

$egular or irregular

Ask all C1 and $ sym)toms

Coffee- do u drink coffee? If yes, ho+ many cu)s or times )er day?

Anemia- any bleeding )oints in your body and 'OC )assed out; and feeling tired?

An6iety-are u an6ious about anything? Any stress in life?

Hy)ogly-do u take your meals regularly? !id you e/er ski) meals? Any relation to meals?heo-any headache, e6cessi/e s+eating, +eakness?

HOC-any sudden death in the family?

F 0 1 & & &

&-&hyroid- any e6cessi/e s+eating, shaky m/nts of hands, any skin changes, heat intolerance?

Closure and advice: lease cut do+n on caffeine

tress counselor-can hel) you by teaching rela6ation te=sIf on thyroid hormone-ha/e regular thyroid le/el check u) and get the dosage accordingly

If hy)oglycemic-donot ski) your meals and ha/e a regular diet

>


4/50

D"SPHA#IA

C-carcinoma eoso)hagus, C1A

A-achalasia cardia

"-"#$! +ith stricture#eoso)hagitisH1,C1, Candida, )ill induced;

-scleroderma or C$#& syndF-foreign body obstruction

"-mystenia gra/is

@-3enkers di/erticulum

-)lummer 1inson synd

(orku): Iron studies&I%C, s. iron, s. ferritin;, &H, )lain c6r, barium s+allo+, C& chest,

endosco)y +ith bio)sy, eoso)hageal manometry, HI1 testing, Anti-centromere antibodies

Associated symps: !o u feel food get struck?

Can u locate +here u feel the food struck?

!o u ha/e difficulty s+allo+ing li=uids or solids of both? If both, then +ith started first?

!o u ha/e any )ain +hile s+allo+ing?!o u ha/e any +ater brash or heart burn?

!id u notice any food )articles on your )illo+ +hen u get u) from your bed?

!id you ha/e any e)isodes of choking?

!o u ha/e any drooling?!o u ha/e any halitosis?

!o your fingers change in color +hen e6)osed to cold or emotions? !id u notice any skin

changes?

Closure and advice-

"ro+th in your food )i)e or infection, foreign body obstruction

&ake soft foods slo+ly in small amounts. If )roblem +ith li=uids then start I1 line, "#$!

counseling


5/50

HOA$SEESS

D/D: $efle6 )haryngitis (orku):

1ocal cord ca Indirect larnygosco)y

'aryngeal ca C%C1ocal nodules or )oly)s &H

1ocal cord or $ecurrent laryngeal ner/e )alsy 4))er "I endosco)yHy)othyroidism


6/50

SO$ETH$OAT

Code: 4 " H I

D/D:Infectous mononucleosis

tre)tococcal )haryngitis4$&I

1iral )haryingitis

%acterial )haryngitis

Acute Hi/ infection

"#$!

(orku):

C%C, )eri)heral smear, onos)ot test

&hroat s+ab for culture sensiti/ity

HI1 ab and /iral load

Anti #%1 abs

1!$' and $$'F&sA&, A'&, bilirubin, A';

Associated symps: !o u ha/e any fatigue, diff s+allo+ing, belly )ain?-I

Any fe/er, runny nose, cough, O%?-4$&I!o u ha/e any facial )ain?-sinusitis

!o y ha/e any ear )ain or discharge?

!id u notice any s+ollen glands2'02dys)hagia? If yes, are glands )ainful?

!o you ha/e any rash, 9oint )ain?- $heumatic fe/er

!o you ha/e any change in color of urine?-"%,"0

!o you ha/e any "#$! sym)s?

Closure and advice:Ad/ice HI1 testing, safe se6ual )racticeA/oid contact s)orts, strenuous e6ercise-&o a/oid the risk of s)lenic ru)ture


7/50

HE%OPT"SIS

D/D:

ulmonary &%ulm edema

%ronchogenic ca%ronchitis

neumonia

ulmonary embolism

'ung abscess

A1 malformation

&or'up:

C%C, C*$, %lood cultures, 4A24C, )iral C&, 'ung bio)sy, %ronchosco)y

! O # F C A A A

C A % C O

%lood-dark colored or fresh blood or blood clots?

Associated symps: do u ha/e any chest )ain or O%?-Heart sym)s

!o you ha/e any +hee3e?-'ung sym)sHo+ is your a))etite? !o you ha/e any e/ening rise of tem)? Any ill contacts? (hen +as your

last !?-&% sym)s

Ha/e u been restricted to any one )osition because of hos)itali3ation or tra/el?-#

Closure and ad/ice:

D


8/50

CO(#H

D/D:

4$&I

&%CO!

Acute %ronchitisbronchiectasis

neumonia

%ronchogenic carcinoma

Foreign body

"#$!

&or'up:

C%C

C*$

)utum for gm stain and culture

!

! O # C F A A A

A-is it +orse during any )art of the day2season2)osture?

!o you bring u) anything in your cough? #g-)helgum. If yes-CA%CO

!o you ha/e any O%? 0!? Ortho)nea? Ankle s+elling? al)itationsracing of heart;,assout?-CO!, CHF

!o you ha/e any runny nose? Facial )ain?

!o you ha/e any dri))ing sensation in your throat?

!o u ha/e any soreness in your throat?

!o u ha/e any +hee3e?

!o you ha/e any +aterbrash? Heartburn? %elly )ain?

!o u ha/e any 55..&% and "#$! sym)s?

A H 4 " F O -AC# inhibitors?

Closure: could be due to hy)ersensiti/ity of your air+ay

Advice:!ont indulge in acti/ities that increase your breathessness

"#$!-ha/e meals < hours before going to bed, no caffeine, no smokinghysiothera)ist for breathing e6ercises

4se tissues +hen u cough

4se face mask +hen you r at +ork

&ake ade=uate rest and nutrition and hydrationIf u are allergic to anything, then a/oid it

E


9/50

)O%ITTI#

D/Dcode: 1 O I & I 0 " H

1- 1ertigo

O-O%")regnancy;, obstruction-igraine, otion sickness

I-Inflammationancreatitis, )yelone)hritis, cholechysitis&-&reatmentchemothera)y, surgeries )aralytic ileus, adhesions;

"-gastroenteritis

H-hy)ercalcemia

(orku):

4rine HC"

el/ic e6am

42 )el/is

C%C, electrolytes, Ca, "lucose

4rine analysis and culture

! O # C F A A AC A % C O

Associated symps:

!o u ha/e any belly )ain?-"astritis!o u ha/e any back )ain? yelone)hritis, )ancreatitis

!o u feel the room is s)inning around you?-1ertigo

!id you eat food outside?-"#

A H 4 " F O

-chemothera)y?

4-4&I sym)s?

O-menstrual historyG Is there any chance of you being )regnant?

Closure and advice:


10/50

BE!!" PAI

D/D: code "OA'I$

":"%-cholecystitis, choledocolithiasis

O: O%"0-I!, #cto)ic )regnancy, endometriosis, adenomyosis, o/arian cyst or torsion:ancreas-Acute )ancreatitis

A:A))endicitis':'i/er-Amoebiasis, hydadid cyst, he)atic congestion

:tomach-"#$!, 4!

I:Intesines-C!, 4C, !i/erticulitis, mesenteric ischemia

$:$enal stones, $CC

(orku):

$ectal e6am

erum Amylase and li)ase

'F& A'&,A&, bilirubin, A';

#ndosco)y for H.ylori testing

4))er "I series

42 abdomenC& abdomen

42 )el/is, 4rine HC"

! O # C F A A A

' I J $

F 0 1 & & & &

!o u ha/e any occu)ational stress?

A H 4 " F O

-+hen +as your last colonosco)y done?H-any )re/ious a))endicectomy or I! history

4-do u ha/e any burning sensation +hile )assing urine? !id u e/er notice blood in urine or +hat

is the color of your urine?-0e)hrolithiasis

"-ho+ are your bo+el m/mts? Ho+ often do you )ass your stools? !o u ha/e any )ain +hile

)assing stools? !id you notice any blood in your stools? (hat is the color of your stools? Any

alternating bo+el habits? CA%CO

Closure and advice:

7K


11/50

B!EEDI# PE$ $ECT(%

D/Dcode: CHA!


12/50

HE%AT($IA

D/D: code HI&$ (orku):

-stones in bladder or ureter "enitourinary e6am

H-hematologic 4rine analysis and cytologyI-infection"% infections, chistosomiasis; %40, creatinine, A

&-trauma &, A&&&-tumor $CC, %ladder ca; 42 renal bladder

#-e6ercise rhabdomyolysis; C& abdomen and )e/is

$- $enal"0, C8!; I1

! O # C F A A A

C-do u see blood e/erytime u )ass urine? If no, then ho+ often?

Ho+ much? (hen did u notice blood? i.e before2during2after2through out )assing the urine

Associated symps:

!o u ha/e any burning sensation?

!o u ha/e to rush to the bathroom to )ass urine? urgency;

!o u ha/e to get u) in the night? nocturia;Ho+ is your stream? any +eak stream;

!o u ha/e to strain to )ass urine? straining;

!o u ha/e to +ait before )assing urine? hesitancy;

!id you ha/e any urinary in9ury?!o you any dribbling or leaking of urine? incontinence;

!id you notice any )us in urine?

!o you ha/e any )ain in your back? flank )ain;

Ha/e u e/er been diagnosed to ha/e kidney stones? Ha/e u e/er )assed stones in your urine?

!o you ha/e any sore throat? Loint )ains? %ack )ain?

!o you ha/e any bleeding )oints any+here in your body?

Ha/e u e6ercised strenuously?

Closure and advice:

7


13/50

*ATI#(E +*eelin, lo- or .eelin, tired

D/D: code HO!CA (orku):

H- hy)othyroidism, HI1 C%C, electrolytes, calcium

O- obstructi/e slee) a)nea, occult malignancy &H!-!, de)ression, domestic /iolence HI1 and &! testing

C-caregi/er fatigue, com)assion fatigue,colon ca olysomnogra)hyA-anemia, ad9ustment disorder 0octural )ulse o6imetry

-myasthenia gra/is, malignancy Colonosco)y

-)regnancy, &!

Associated symps:

Hy)othyroidism- do you ha/e any )roblems ad9usting +ith surrounding tem)? !o you ha/e any

sonsti)ation? Any hair fall? Any hoarseness of /oice? Any dryness of skin? Any belly )ain or

discomfortfor consti)ation;?

OA- !id anyone notice u snoring at night? !o you feel refreshed after +aking u) in the

morning? !o u feel tired and slee)y during daytime?

HI1 and malignancy- Ho+ is your a))etite? !o u ha/e any recent +eight changes?

!e)ression- Ho+ is your mood? If good, then ask for IC# MHo+ is your interest no+adays? (hat are your hobbies? !o u en9oy them?

Ho+ is your concentration?

Ho+ are you energy le/els?

If mood is bad, then ask for "- Ho+ is your slee)?

I- interest?

"-guilty?

#- energy?

C- concentration?

A- a))etite?

- )sychomotor changes? any irritability;

-suicidal tendencies? do u feel like hurting yourself?; If yes, then gi/e suicidal counseling

!- do u feel any increase in thirst and hunger? !o you feel any increase in fre=uency or

urination?

!omestic /iolence- are u being )hysically or emotionally hurt or abused by anybody? Are you

feeling safe or are u afraid at home?

Anemia-do u ha/e any racing of heart? Any O%? Any belly )ain? Any bleeding )oints?

Ad9ustment disorder- do u ha/e any stress at +ork or home?

yasthenia gra/is- did u notice any droo)ing of eyelids? Any double /ision? Any increasedfatigue to+ards the end of the day?

&!-do u ha/e any flashbacks or nightmares of any e/ents?

It sound like u are losing ho)e. Ha/e u e/er thought of hurting yourself or try to do so?

Closure and ad/ice:

7>


14/50

HEA$I# !OSS

!2! code: A0F'OI&

-meniers disease

A-acoustic neuroma0-noise indused

F-foreign body'-labrynthitis

O-otosclerosis, ototo6ic drugs, otitis media

-)resbycusis, )erilym)thatic fistula

I-im)acted +a6

&-trauma

(orku):

audiometry,

tym)anometry

C& head

brain stem auditory e/oked )otentials

C%C, #$, electrolytes, 1!$'

Hello r.6, y nurse told me that u ha/e )roblem +ith your hearing. Am I audible to you? !o u

+ant me to come closer. ay I kno+ in +hich ear u can hear me from this )osition? If both years,

then say Nsorry.%e near to the ear in +hich the can hear and start your introduction: I am !r.$a/i, the

attending )hysician in this medical center and I +ill be taking care of you today555..

Associated sym)toms:

Otitis media and labrynthitis-do u ha/e any ear )ain? If so then ask 'IJ$. !o u ha/e any ear

discharge? ask CA%CO;. !o u ha/e a runny nose, sore throat, cough? !o u ha/e any

imbalance? !o u ha/e any ringing sensation in the ear? !o u ha/e any fullness in your ear? !o

you ha/e any feeling of room s)inning around u?Ha/e u e/er been e6)osed to loud noises?

Acoustic neuroma- do u ha/e any headaches? Any facial )ain or facial +eakness? !o u ha/e any

/ision )roblems?

F%- did u insert any fb either accidentally or intentionally in to your ear?

&rauma- did u e/er ha/e any trauma to your ear?

Is there any h2o recent infection and treatment?

Ototo6ic drugs- as)irin, HC&@, aminoglycosides,

!o u hear +ords 9umbled or distorted?

Can u locate the source of sounds?

!o u ha/e any )roblem understanding s)eech?

!oes it effect your life style?

F 0 1 & & & & - did you ha/e any airtra/el recently or scuba di/ing?

7


15/50

#6amination: do $innes, (ebers, sinuses, C0s

Closure and ad/ice:#ar )lugs- I can +rite a letter to your em)loyer to shift u to noise free )laces.

It is ob/ious from my e6amination that you ha/e hearing loss, but it could also be due to somere/ersible causes. &reating them may restore your hearing and for that I need to rule out some

re/ersible causes.

ean+hile, +ith your )ermission I +ill make an a))ointment +ith an audiometrist +ho can hel)

u +ith some hearing aids.

CJ: Am I going to be deaf?

7B


16/50

DI00IESS

!2! code: HO%'AA

H-hy)oglycemia

-meniers diseaseO-orthostatic htn

%-%1'-labrynthitis

A-acoustic neuroma

A-arrythmias

-)erilym)hatic fistula trauma;

-stroke

(orku):

-1!$', $$

O-orthostatic /ital signs

%-audiogram, dicks hall)ikes maneu/ure

C%C, electroly, blood sugar

C& head, $I brain

Associated sym)toms:

(hat e6actly do u mean by di33iness?

! O # C F A A A: A-)osition and time

H-Ha/e u ski))ed any meal?

-do u ha/e any )roblem +ith hearing? Any ringing sensation in your ear? Any sensation of

room s)inning around you?

'-do u ha/e any ear )ain? #ar discharge? Any runny nose? ore throat? Cough?

A- do u ha/e any headaches? 1ision )roblems? Facial +eakness?

A-do u ha/e any racing of heart? Chest )ain? O%?

-do u ha/e any +eakness or numbness or tingling any+here?

#6amination:

Closure and ad/ice:

!o not change your )osition suddenly donot get u) suddenly from lying do+n or sitting do+n

)osition;

4se hand railings +hile u +alklease dont dri/e or go unaccom)anied +hen u go out

!o carry an I.d card +ith )hone numbers of your lo/ed onesA/oid high altitudes

7


17/50

ISO%IA

!2!: code "C$O4!

"-generali3ed an6iety disorder

-meno)ause, medicationsC-circadian rhythm slee) disorders, coffee

-&!, hy)erthyroidism$-restless leg synd

O-obstructi/e slee) a)nea

4-4&I, %H

!-de)ression, diabetes mellitus

(orku):

olysomnogra)hy

#mental state e6amination;

&H

C%C

#C",##"

4rine to6icology

! O # F A A

!-+hen did it start?

I need to ask u fe+ =s about your slee) )attern. Is that ok +ith you?!o u ha/e )roblems falling aslee)?

Falling aslee)-+hen do u usually go to bed? Ho+ much time do u take to fall aslee)? (hat do u

do before u go to bed? !o u e6ercise? !o u take e6cessi/e coffee or alcohol before going to bed?

!o u +atch t/? moke?

!o u ha/e )roblems staying aslee)?

taying aslee)-Ho+ many hours do u slee)? Ho+ many times do u +ake u) in the middle of the

night? (hat do u think is causing it?

!o you ha/e )roblems like unusual +aking u) early in the morning?

4&I2%H2diabetes mellitus-do u +ake u) to urinate in the middle of the night?

An6iety- are u an6ious about anything?

"#$!-555.ask "#$! sym)s;

eno)ause- do u ha/e any hot flashes? #6cessi/e s+eating?

Circadian rhythm-do u ha/e any recent changes in +ork shifts?

&!-do u get any nightmares or flashbacks of those e/ents?

$estless leg syndrome- does any one notice fre=uent m/mts of your legs during your slee)?

OA-do u feel slee)y during daytimes? !o u feel refreshed after u +ake u) in the morning? !o u

feel slee)y during the day? !id anyone notice u snoring +hen aslee)?

!e)ression-ho+ is your mood?

If good, then ask interest,conc, energy le/elsIC#;

7D


18/50

If bad, then ask I"#CA

#6amination:

In C0, do # i.e OCL;

O-orientationtime,)lace,)erson;do u kno+ +hat time of the day it is? !o u kno+ +here are ukno+? !o u kno+ +ho I am?

-memoryremote,recent,immediate; +hat is your date of birth? (hat did u ha/e for lunch

yesterday? Ill tell you the name of > things, )lease re)eat them for me

C-concentration-Can u s)ell the +ord book back+ords for me?

L-9udgement-+hat +ill u do if u see a cloth catching fire?

If you dont ha/e time for #, ask the )t +hats his name? +here are you? +hos the

)resident of 4? (hat day is today?

Closure and ad/ice:

lease maintain a slee) diaryFollo+ regular bedtime and +akeu) times

!ont e6ercise in early e/enings

!onot take caffeine or alcohol and donot smoke before going to bed

lease a/oid +atching t/ on bedA/oid daytime na)s

7E


19/50

HEADACHE

!2!: code CA$&

C-cluster headache, cocaine

A-anesthetic +ithdra+al-sinusitis, subdural hematoma, AH

$-refraction headache-migraine,meningitis

&-tension headache, tumor, trauma, tem)oral arteritis

-)seudotumor cerebri, )rolactinoma, )hreomochromocytoma, )remenstrual synd

(orku):

C%C, #$, electrolytes

C& or $I brain

C& of 0

'

Cluster-do u ha/e )ain around your eye? Any +atering of eyes? Any runny nose?

igraine- do u ha/e any +arning signsnausea,/omiting; b2f the onset of headache? !o u ha/eany discomfort +ith bright light?

eningitis-do u ha/e any neck stiffness? !o u ha/e any ear )ain? #ar discharge? !id u e/er

thro+ a fit?

$efraction and tumor-do u ha/e any /ision changes? !o u ha/e any stress at +ork?

&em)oral arteritis- do u ha/e any 9a+ )ain +hile che+ing?

&rauma- did u ha/e any trauma to your head?

inusitis-!o u ha/e any runny nose? facial )ain?

seudotumor cerebri- do u ha/e any +eakness in your arms or legs? Any tingling or numbness or

+eakness in your arms or legs? !o u ha/e any difficulty in s+allo+ing? Any slurred s)eech? Any

changes in /ision? Any urinary or stool incontinence?

F 0 1 & & & trauma and tumor; A H 4 " F O

-oc )ills, /itA to6icity, tetracycline to6icity

O-occu)ational stress

#6amination: head, C0s, $4C;

Closure and Ad/ice:

7


20/50

!OSS O* COSCIO(SESS +!OC

t c2o faint e)isode, )ass out or blackout;

!2!: code HO&A1!

H-hy)oglycemia, heat e6haustion, hy)o/olemia, HOCO-orthostatic hy)otension

&-tumor, traumaA-arrythmias, anemia, aortic stenosis

-stroke, &IA, AH,sei3ures, substance inducedcocaine;

1-/aso/agal synco)e, /ertigo

!-drug induced

(orku):

%lood glucose

erum electrolytes, C%C

Orthostatic /itals

C& or $I brain

#8", #CHO, Holter monitoring

##"4rine to6icology

! O #- #-do u relate this )roblem to any e/ent?;

Associated sym)s:

Is this the first e)isode2If no, ho+ many )re/ious e)isodes?

For ho+ long did u lose your consciousness?

!id u lose your consciousness b2f or a2f your fall?

ei3ures-did u smell, see or hear anything unusual or any +arning signs b2f the e/ent? !id

anybody notice shaking or 9erky m/nts of your body? Any tongue biting? Any frothing? !id u

)ass any urine unkno+ingly?

C1-did u ha/e any racing of heart? Any chest )ain?

troke or &IA-did u ha/e any light headedness? Any +eakness or tingling or numbness in your

body?

Hy)oglycemia-did u ha/e any e6cessi/e s+eating? !id you ski) any meal b2f this e/ent?

Heat e6haustion-did u notice any dry mouth b2f the loc?

1ertigo-did you any s)inning sensation or ear )ain? !o you ha/e any )roblem balancing +hile

you +alk?

&rauma-did u ha/e any trauma to your head?

HOC-ha/e you e6ercised strenuously b2f u lost your consciousness?

Hy)o/olemia- did u ha/e any loose stools recently?


21/50

After the e/ent;- did you ha/e any confusion? Any numbness? Any tingling? Any

headache2nausea hy)oglycemia; after the e/ent?

In family history, ask for any sudden deaths

#6amination:

If hy)ertension )resent, do C1If sei3ure acti/ity, do C0 and H##0&

Closure and ad/ice:

lease dont dri/e or go unaccom)anied +hen u go out

!o carry an I.d card +ith )hone numbers of your lo/ed ones

A/oid strenuous acti/ities, e6ercise

A/oid illicit drugs

555until I get your results

CJ:

y +ife asked me to dri/e car, can I?

!id I )ass out due to cocaine?Can I go )lay a match?

Is this the same attack as that of my brother? HOC;


22/50

CO*(SIO O$ *O$#ET*(!!ESS

!2!: code 1A0IH#!

1-/ascular dementia, /it%7< deff

A-al3heimers , AI!0-0H, neurosy)hilis

I-intracranial tumors, infection-IA!H, chronic subdural hematoma

H-hy)othyroidism, hy)oglycemia

#-ence)halitis, electrolyte imbalance

!-de)ression, drugs, diabetes mellitus

(orku):

#


C& or $I brain

erum %7< le/els

!o))ler 42 carotid

$%,%40,creatine' +ith o)ening )ressure

If family members tell you about it, then ask since ho+ long he2she has been concerned about

this.

! O #

!id u or anybody notice it?

Is it affecting your daily acti/ities?-code !#A&HHAF&

!o you ha/e trouble +ith dressing? #ating? Accounts management? &oiletingusing restroom;?

anaging sho))ing? House kee)ing? Accounting? "oing around or finding home? Cooking?

&ra/el or dri/ing?

Ho+ is your mood? Ask for IC# and I"#CA

C0s-do u ha/e any )roblem +ith s)eaking? +allo+ing? 1ision?

otor-do u ha/e any +eakness in your body?

ensory2/it%7


23/50

(ith your )ermission, I need to talk to your family members to better understand your )roblem

#6amination: #, C0, $motor,sensory,refle6es,)ulses;

Closure and ad/ice:

ou ha/e some )roblem +ith your concentration and memory. It might be due to a )roblem inyour brain or +ith the /essels su))lying your brain or but there are also many other )ossibilities.

o I need to run do+n a fe+ blood tests and imaging studies of your brain

8ee) things organi3ed in your room

aintain a diary listing your acti/ities

!onot dri/e alone

Al+ays be accom)anied by others +hen u go out

lease carry an i.d +ith contact numbers of your lo/ed ones

CJ: is it because I am getting old? (ell, I can understand555.."etting old doesnot mean you

ha/e to ha/e forgetfulness. It could be one reason but there are also se/eral other causes +hich

need to be ruled out and some of them can be effecti/ely treated. In order to be sure I need to run

do+n a fe+ tests55555..


24/50

&EA1ESS I A$% O$ !E#

!!: (orku):

&IA C& head, $I brain

Com)licated migraine !o))ler 42 carotidIntracranial neo)lasm $%, H%A7C le/els

Chronic subdural hematoma erum %7< le/elsHy)oglycemia 0er/e conduction studies

!iabetic )eri)heral neuro)athy C%C, #$, electrolytes

Alcoholic-%7< deficiency

"%

$adiculo)athy

C2O +eakness in arm or leg

! O # C F A A

- )ro6imal to distal

!istribution: +hich )arts of body are in/ol/ed?

ensation: any tingling or numbness? Any )ain? Any headache? Any neck )ain? Any back )ain?If headache )ositi/e then rule out migraine

ei3ures: did you e/er thro+ a fit?

C0-any difficulty in s+allo+ing? In s)eech? In breathing? In /ision?

A0-did you e/er )ass urine or stools unkno+ingly?

Hy)oglycemia-did you e/er ski) your meals?

F 0 1 & & &

&-traumasubdural or e)idural hematoma;

A H 4 " F O -!, H&0, Atherosclerosis

Closure and ad/ice:

A))ointment +ith a )hysiothera)ist


25/50

A(DITO$" HA!!(CIATIOS

!2!: code %A!0

%-%rief )sychotic disorderP7mnth;-due to medical2)sychological2electrolyte imbalance

A-ad9ustment disorder!-drug2substance induced )sychosis

-schi3o)hreniform disorder 7- mnths;G if Mmnths then its schi3o)hrenia-sei3ures

0-narcole)sy

(orku):

4rine to6icology drugs;

C& head and $I brain

C%C,#$, electrolytes

%40, ser creatinine, A'&,A',A&

chi3oaffecti/e disorder schi3o)hrenia Q mood disorder i.e either de)ression or mania

r.*, my nurse told me that you are hearing /oices. lease donot listen to them. &hey are

imaginery not real;. lease concentrate on me r.6. I am here to hel) u and I can do that if youshare your )roblem +ith me. I assure you that e/erything +e discuss +ill be ke)t confidential.

&o interru)t the )t-

#6cuse me r.6, I am sorry to interru)t you. I kno+ these things are bothering u. I need to focus

com)letely on your )resent situation. lease dont concentrate on them, try to concentrate on me.

I understand that you are going through a tough )hase. (e +ill definitely +ork on it together.

!o u hear those /oices e/en +hen you close your ears?

!o you think /oices are controlling you?

! O # F

Auditory-ho+ is it affecting your daily acti/ities?Ho+ many /oices do you hear?

(here do u think they are coming from?

Are u familiar +ith those /oices?

(hat do they say?

1isual-do you see something that others dont? (hat do you see?Ho+ long ha/e u been ha/ing this )roblem?

Olfactory-do you smell anything that others dont?

ensory-do you feel something cra+ling on your body?

uicidal tendency-did you e/er think of hurting yourself2others?

!o you ha/e any )ills2guns in your house?

!elusion-do you ha/e beliefs that others find odd?

ania-do u feel elated?

ood-ho+ is your mood?-IC# and I"#CA


26/50

$elationshi)-ho+ is your relationshi) +ith the family? Are they hel)ful?

!o you ha/e anyone to share your feelings +ith?

Any +eakness2numbness2tingling2incontinence2slurring of s)eech2headache2sei3ures

#6amination:#

C0

0eck-carotid auscultation

CJ:Am I going mad?

r.6, I can understand your a))rehension. Hearing /oices doesnt mean that you are going mad. I

ha/e seen many cases of this kind, +ho are doing +ell no+. %ut to be sure of the diagnosis, I

need to run do+n some tests. lease dont +orry. (hate/er may be the !6, I am here to hel) you

out and gi/e u the best $6 o)tions a/ailable at our hos)ital.


27/50

OIT PAI:

! O # C F A A A ' I J $

Associated sym)s:!id you notice any redness or +armth or s+elling or stiffness?-inflammatory signs;

!o you hear sounds +hile mo/ing your 9oint?!o u ha/e any decreased mo/ent at the 9oint?

!id you do any /igorous e6ercise?

!id you lift any hea/y +eight?for back )ain;

Is it affecting your daily acti/ities?

Are there any similar sym)s in other 9oints?

otor:

!o you ha/e any +eakness any+here in your body?

ensory:

!o you ha/e numbness, tingling? Or )ain else+here in your body?

Autonomic:

!id you e/er )ass urine or stools +ithout your kno+ledge?

ulti)le myeloma-do you ha/e light headedness? Consti)ation? $acing of heart?headache? belly)ain?ask only if back )ain;

F 0 1 & & & &

F-any fe/er?se)tic arthritis;

&-did you ha/e any trauma to your 9oint?

&-tumor-)rostate,lung,breast,multi)le myeloma,lym)homa

C I & $ 4 H &C- runny nose, cough, chest )ain?-/iral infection;

I-infection?-4&I;

&-tick bite?

$-any rash on your body?

4-any ulcers on your body?

-any stiffness of your 9oints?

H any hair loss?

-any )hotosensiti/ity?

&-tem)erature: any changescolor; of fingers on e6)osure to cold?

A H 4 " F O - steroids, H$&,/it!?

4-4&I?

-any disturbed slee) in lying do+n )osition?

O-meno)ause, I4! insertion

-erections2e9aculations )roblems?

#6amination:

tart +ith the normal 9oint


28/50

Ins)ection-look for any redness, s+elling or abnormalities?

al)ation-feel for any +armth,tenderness and for range of mo/ementssay to do as much as

)ossible but dont e6ert your self. If you get any )ain, )lease sto) immediately;

For s)ine-untie


29/50

EC1 PAI:

!2!:

aras)inal muscle strain (orku):

Cer/ical s)ondylosis *ray neck-A and lateral /ie+Cer/ical disc )rola)se or herniation 0er/e conduction studies

$adiculo)athy erum ca )hos)hate and A'$A C%C, #$, serum electrolytes

&raumatic fracture of cer/ical s)ine erum A0A and $F

!egenerati/e disease-Osteoarthritis of cer/ical s)ine

For neck )ain, shoulder )ain, elbo+ )ain-dont gi/e shake hand

For neck )ain-first knot only

Closure and advice:

CA!* PAI +D)T

!!:!1&

Cellulites2myositis

$u)tured bakers cyst

Hamatoma

$u)ture of medial head of gastronemius

)asm due to in9ury or s)rain

Claudication

(orku):

!o))le 42

C& chest, 12J scan

!-dimers

Hy)ercoaguability testing

C%C and !C, #$C8 and myoglobin le/els

C& /enogra)hy

$I legmuscle2tendon ru)ture;

%lood for C2

! O # C F A A' I J $

Associated sym)s:

!id you notice any redness in your legs? rubor;

!o you ha/e the sensation of +armth in your legs? calor;

!o you ha/e any s+elling in your legs?tumor;

'oss of function-Are you able to more your knee 9oint?dolor;


30/50

1aricose /eins-!id you notice any enlarged or dilated /essels on your legs? Any ulcers on legs?

#-!o you ha/e any O%? Any chest )ain? Any cough?

F 0 1 & & & &F-!1&, cellulitis and myositis;

&-traumaany immobili3ation?;,&-tra/el, &-tumorhy)ercoaguability state;-)reci)itating factorsfor !1&

A H 4 " F O

-)re/ious h2o arthritis $A;

-oc)s )reci)itate clotting

H-ortho)edic surgeryimmobili3ation;

F-cholestrolemia, clotting disorders

O-)regnancies, immobili3ation

- i/ drug use

-smokingincreases clotting;, sedentary occu)ation if elderly ;

#6amination:Ins)ection-look for any redness, s+elling or abnormalities?

al)ation-feel for any +armth,tenderness and for range of mo/ements at knee say to do as much

as )ossible but dont e6ert your self. If you get any )ain, )lease sto) immediately;

#licit ratts signs=ee3ing of )osterior calf causes )ain; andHomans sign)assi/e dorsifle6ion of foot causes )ain in calf;

C1 and $ auscultation for #

$- -lo+er limb )ulses

Closure and ad/ice:our condition could be due to a clot in the blood /essel or any infection.

If your results slo+ cots, +e +ill start blod thinners +hich )re/ent further com)lications such as

clot tra/eling to your legs

A/oid immobili3ation for long )eriod of time&ry to mo/e in )lace and )erha)s take a short +alk

If on OCs, )lease sto) using them as this may +orsen the condition.

tudies ha/e sho+n that obesity increases your risk of ha/ing a clot. o, I suggest that you

e6ercise regularly and manage your diet

>K


31/50

DIABETES %E!!IT(S *O!!O& (P

(ell r.6, I am glad that you are here. I a))reciate that you are taking good care of your health.

Ho+ can I hel) you?

atient here for a refill:

I am glad to hel) you. %efore I refill your medication, I need to ask you some =s and do a small)hysical e6amination.

(hen +as it first diagnosed?

ay I kno+ +hat medications you are on?

Are you com)liant +ith your medication?

(hen +as your last doctor /isit? ay I kno+ the result?

!o you check your glucose le/els regularly at home? ay I kno+ the readings?

$etino)athy-!o you get your eye check u)s done regularly? (hen +as the last check u) done?

!o you ha/e any blurring of /ision? !o you ha/e any headaches?

0euro)athy-!o you ha/e any numbness, +eakness or tingling sensation?!o you ha/e )roblems controlling your urine or stool?

!o you ha/e any ulcers or re)eated in9uries to your legs?

Atherosclerosis-!o you ha/e any chest )ain? Any e6cessi/e s+eating? And lightheadedness? Anybelly )ain?

4rination-!o you +akeu) at night? If yes, ho+ many times? Is it disturbing your slee)?

!o you ha/e any burning micturition?

e6ual dysfunction-!o you ha/e any )roblems +ith your se6ual life?

!o you ha/e any early morning erections?

A H 4 " F O

#6amination:

Fundosco)y

0eck, C1, ulmonory

Abdomen#6tremities and 0eurological

(orku):

H%A7C le/els%40, Creatinine

C%C, s.electrolytes

Closure and ad/ice:

$egular eye checku)s

&ake small fre=uent meals and )lease donot ski) meals

4se soft heel )ad shoes

!ont in9ure yourself. If in9ured take )ro)er care as early as )ossible

&ake a diet lo+ in salt, carbs and fat and high in fiber

#6ercise regularly

>7


32/50

*E%A!E CASES

)A#IA! B!EEDI#

!2!: A1%'##!

A- adenomyosis, abortion1-/aginal in9ury

-I!, CO!, )erimeno)ause

%-bleeding diasthesis

'-leiomyomas-hea/y )ainful menstruation, dys)erunia,

#-ecto)ic )regnancy#-endometriosis,endometrial ca

!-!4%, hy)othyroidism

(orku):

el/ic, genital and rectal e6am

4rine HC", 4 )el/is

Cer/ical cultures, endometrial bio)syA smear

&2A&&

'H2FH, )rolcatin,&H

Juantitati/e serum HC"

! O # F A A

F-is it continous flo+ or is it s)otting?

Is this the time +hen you usually get your )eriod?

Associated sym)s:

!o you ha/e any )ain associated +ith bleeding? If yes, 'IJ$. Is it bright red or does it ha/e

clots? !oes it contain any tissue like substance?

1-did you ha/e any trauma or accident?

%-do you ha/e any belly )ain? !o u ha/e any racing of heart? Ankle s+elling? ass outs? !o you

ha/e any bleeding )oints in your body?

A-+hen +as you '? If 'MB +ks, are there any chances of you being )regnant? Are you

cycles regular? Ho+ often do you get them? Ho+ many days do you bleed? Ho+ many )ads do u

change on a healthy day? !o u notice any intermenstrual s)otting? Any )ain during

menstruation? (hen +as your A smear done? If no then gi/e ad/ice. If yes, can I ha/e the

result?

-I!;do you ha/e any /aginal discharge? If yes CA%CO!o you ha/e any /aginal ulcers? Any dryness? Any itching?

erimeno)ause-!o you ha/e any hot flushes?if flushes yes, then did u try any medication for it?

#ndometriosis-!o you ha/e any )ain during menstruation? !uring intercourse? !uring

urination? !uring )assing stools?#ndometrial ca-!id u notice any bleeding after intercourse?

Orthostatic hy)otension-difficulty breathing, di33iness, lightheadedness, heart racing, chest )ain

>


33/50

O%-ha/e u e/er been )regnant before? !o you ha/e any kids? Ho+ are they deli/ered?

!id u ha/e any com)lication during )regnancy? !uring deli/ery?

!id you ha/e any miscarriages?

F 0 1 & &thyroidR; &tumorR;

A H 4 " FO blood thinnersR;

Fbleeding disorders, multi)le abortionsR;

cocaine/asoconstrictionabortionR;

Closure and Ad/ice: t has di33iness-

our condition a))ears to be an emergency for me. lease dont take anything by mouth until the

in/estigation results are out. y nurse +ill be checking for your /itals regularly.

It can be due to com)lication of unkno+n )regnancy, abnormal hormone le/els or any infection.

aintain genital hygiene )ractice safe se6;, take )lenty of fluids, take ade=uate rest

!ont in/ol/e in acti/ities that increase discomfort

Iron and calcium su))lementation

A%EO$$HOEA

!2!: &AA or A


34/50

erimeno)ause and remature o/arian failure- do u ha/e any hot flashes? Any night s+eats? !id

u notice any mood changes recently2 do u feel irritable? any )ain during intercourse? Any dryness

in your )ri/ate )arts?

rolactinemia do u ha/e any headache? Any /ision )roblems? any ni))le discharge?

CO!-did u notice any e6cessi/e hair gro+th on your face?

&hyrod- Js

Anore6ia ner/osa- any +eight changes?

remature o/arian failure and )erimeno)ause- any hot flashes? !ryness in )ri/ate )arts?

!e)ression?-if mood good then ask IC#. If bad ask I"#CA

ost )ill amenorrhea-are you using any OCs?

#6amination:%elly

Occular m/nts,/isual fields-)ituitary tumors,hy)er)rolactinoma;

$efle6eshy)othyroidism;

el/ic e6am- In the later )art of the day

Closure and ad/ice:

#6ercise to reduce +eightCO!;

Calcium and iron su))lementation

In/ol/e in )leasurable acti/itiesmeno)ause;

CJ:

4n)lanned )regnancy?I understand your an6iety about this un)lanned )regnancy. I ad/ice you to discuss this +ith your

husband. As your )hysician, I +ant to assure you that I am here to su))ort and ad/ice you

regardless of the decision you make. If you +ish, I +ould be ha))y to discuss your o)tions +ith

both of you.

Can I take H$&?I can understand your concern. Once the results are out, I +ill be in a better )osition to tell you

+hat e6actly is causing your )roblem. If your condition re=uires H$& then I +ill be more than

ha))y to )rescribe it to you.

>


35/50

)A#IA! DISCHA$#E

!2!:

%acterial /aginosis

Candidial /aginitis&richomonas /aginitis

Cer/icitisChlamydia and gonorrhoea;4rethritis

I!

(orku):

el/ic e6amination

(etmount and 8OH )re)aration of /aginal discharge

Cer/ical cultures, 0AA&, 4! abdomen

4rine for C2

4rine for %HC"

! O # F C A A A

C A % C O!o u ha/e any ulcers in your )ri/ate )arts? any dryness of your )ri/ate )arts? any itching of your

)ri/ate )arts?

!o u ha/e any )ain during intercourse?

4rethritis-do you ha/e any % F 4 0 H I ?

%-burning, Fre=uency, urgency, nocturia, stream2strain, incom)lete e/acuation, )ain or )us

"onorrhea- do u ha/e any rash on your skin? Any 9oint )ains?

F 0 1 & & &&any trauma to your )ri/ate )arts?;

edications-any OC )ills or any steroid use?

#6amination:

%elly e6, C1A tenderness of 4&I

"#-look for mouth ulcers or sores

Closure and ad/ice:

It could be due to an infection of your )ri/ate )arts or infection of your urinary tract or anycom)lication of )regnancy.

aintain )ro)er hygiene of your )ri/ate )arts+ash regularly and kee) it dry;

ractice safe se6ual methods

&ake )lenty of fluids, nutritious diet, ade=uate rest

If #$ case: your condition seems to be an emergency. lease donot take anything by mouth untilthe instructions are )assed. Once I am done +ith this, I +ill send my nurse to monitor your /itals

and gi/e you I1 fluids and a))ro)riate medications.

>B


36/50

D"SPA$E(IA

!2!:

1ul/odynia

1aginismusAtro)hic /aginitis

Cer/icitis#ndometriosis

I!

!e)ression

!omestic /iolence

(orku):

el/ic e6am

8OH and (etmount )re)aration

Cer/ical cultures

42 )el/is

la)rosco)y

! O # F C A A A and ! 4 ! I

F 0 1 & & & and A H 4 " F O

! 4 ! I

!o u ha/e any discharge? Any ulcers? Any itching? Any dryness in your )ri/ate )arts?

!o you ha/e any belly )ain?for cer/icits, endometriosis, and I!; and ask for these res)ecti/e

sym)toms

Are u safe at home?

Ask for mood and relations

Closure and ad/ice:

CJ: +hy are you asking me this =uestion are u safe at home?;

I am concerned that domestic maybe in/ol/ed and my goal is to make sure that you are in a safeen/ironment and not a /ictim of abuse.

>


37/50

SAPPI# Bein, irrita3le .or silly t4in,s

!!: code "HAO

eno)ause

"A!generali3ed an6iety disorder;Hy)erthyroidism

Anemialee) disorder, se6ual )roblem

Occult malignancy

(orku):

erum 'H, FH

erum &>, &, &H le/els


erum iron studies and H%

eno)ause-Ask for meno)ause sym)toma

"#!-are u an6ious about anything? !o you ha/e any stress in your life?

Anemia- do you ha/e any bleeding )oints? Any racing of heart? Any di33iness?Hy)erthyroidism? Any e6cess s+eating? Any shaky m/ts in hands? Any irritability? Any )roblem

ad9usting to surrounding tem)? Any a))etite and +eight changes?

Occult malignancy-any a))etite and +eight changes recently?

lee) disorder-do you snore? &otally, ho+ many hours do you slee)?(hom do you li/e +ith? Ho+ is your relationshi) +ith them?

"#:

&hyroid and )ulses

C1

'ungs

!&$ increased in hy)erthyroidism

Closure and ad/ice:

It may be due to hormonal changes or normal changes +ith aging?

%e in/ol/ed in )leasurable acti/ities

)end time +ith your lo/ed onesfriends and family;

&ake iron and calcium su))lementationIf stress )resent, a))ointment +ith stress counselor

>D


38/50

ICOTIECE

!2!: code O40!

-stress incontinence

O-o/erflo+ incontinence4-4&I, urge incont

0-0ormal )ressure hydroce)halud!-! and !I

(orku):

el/ic e6am

Cystogram

4rodynamic study

4A and culture

Jti) test

C& head

$% H%A7C

! O # F C A A AF-ho+ often do you ha/e these accidents? Is there any s)ecific time or e/ent associated +ith

these accidents?

!oes it affect your daily acti/ity?

!oes it affect your se6ual life?!oes it affect your inter)ersonal relationshi)s?

!o u use any absorbent )ads? If yes, ho+ many?

Ask for %F40HI but dont ask for stream;

!o u ha/e any /aginal discharge?

!id u e/er thro+ a fit? Any headache? Any +eakness of your limbs?-0H

!o u ha/e any increased fre=uency of your urination and ho+ is your thirst?-!

F 0 1 & & & &&-any trauma to your back or )ri/ate )arts?

O%:

Ho+ many )regnancies did you ha/e? (hat +as the mode of the deli/ery? Force)s or 01! or

C?

Closure and ad/ice:

#m)ty your bladder as fre=uently as )ossible.

&ry to take an aisle seat +hile you tra/el

Cut do+n on your alcohol and caffeineI ad/ice you to use absorbent )ads.

(ith your )ermission I +ould like to a))oint a )hysiothera)ist +ho can teach you somestrengthening e6ercises for you )el/ic muscles and I +ill be there through the )rocedure.

>E


39/50

I%POTECE or SE5(A! D"S*(CTIO

!2!: code !HA&

!-!, drugs%eta blocers, diuretics;, de)ression

-stress induced, stroke-)erformance an6iety, )ost I, )ituitary dysfunction

H-htnA-atherosclerosis

&-trauma to back

(orku):

"enital and rectal e6am

%, C%C

tam) test

li)ids, )el/ic !o))ler

&estosterone

$%

! O # F A AF-do u ha/e this )roblem e/ery time you )erform se6?

Ho+ is your desire?

On a scale of 7 to 7K, +ith 7 being flaccid and being 9ust able to )enetrate, ho+ do u grade your

erection?!o u ha/e any )roblem +ith e9aculation?

!id u obser/e early morning erections? if yes-)erformance an6iety;

Are u an6ious about se6?

(ho is your )artner?

!o u ha/e any other )artners? If yes, do you ha/e this )roblem +ith all the )artners?

If no, ho+ is your relationshi) +ith your )artner?

Ask for ! 4 ! I sym)toms

ituitary- do u ha/e any headache? Any /ision changes?

C0-do u ha/e any +eakness or numbness or tingling any+here in your body?

A0-do u )ass urine +ithout your kno+ledge? !o you )ass stools +ithout your kno+ledge?

Atherosclerosis-do you ha/e any )ain in your legs +hen +alking?

!e)ression-ho+ is your mood? If good, ask for I"#CA

F 0 1 & & &&-any trauma to your back or )ri/ate )arts?

!o you any stress at +ork?

!o you use 1iagra or sildenafil?

#6amination:

C1-back

C0- 'o+er limbs-$

>


40/50

PEDIAT$IC CASES

For an emergency case child is in #$ and mother in e6aminees room;

CJ: doc, my child is in #$. 'ets go and see my child no+.I am really /ery sorry that your child is in #$. I can understand that you are /ery an6ious about

your childs health, but donot +orry, your child is in safe hands. (e ha/e a /ery good intensi/e

care team at our hos)ital +ho +ill take care of your child /ery +ell. our emotional stability is

/ery im)ortant for your childs health, )lease be strong.

&o kno+ more about your childs )roblem, I +ould like to ask you fe+ =s and +rite do+n notes

+hile +e talk. I assure you that I +ill be as =uick as )ossible. o )lease bear +ith me for some

time. As soon as I am done +ith my =s, I +ill go and e6amine your child )ersonally. Is that ok

+ith you? hall I )roceed?

Ok s.*, I am !r.$a/i the attending )ediatrician at this medical center and I +ill be taking care

of your child today5555..

(hat is your childs name? ho+ old is he2she?

ay I kno+ +hy is he in the IC4?

other gi/es com)laint55..ho+ em)athy5555..

Can you tell me more about your childs )roblem?

! O # C F A A A

Child at home and mother in room:

Hello s.*, good morning. I am !r.$a/i, the attending )ediatrician at this medical center. 0ice

to meet you.

(hat is your childs name? ho+ old is he? (here is he right no+? (ho is taking care of him?

Ok s.*, ho+ can I hel) you?

other gi/es com)laint5555.

"i/e em)athy5555..Can you tell me more about your childs )roblem?

! O # C F A A A

CJ: doc, +hy are you so late. I ha/e been +aiting for you since a long time.

I am /ery sorry for the delay s.*. I +as encountered +ith some une6)ected delay. 0o+ I am

here +ith you and I assure that I +ill gi/e my uninterru)ted attention.

*E)E$

hone case:

Hello, I am dr.ra/i, the attending )ediatrician2)hysician at this medical center and I +ill be taking

care of your call today.

ay I kno+ +ho I am s)eaking to? Ho+ is he2she related to you? (ith +hom is the baby staying

+ith?

Ok s.6, ho+ can I hel) you?

I am sorry to hear your childs )roblem. I +ill do my best to hel) your child in this regard. For

that I need to ask fe+ =s and make a short note +hile +e discuss. Is that ok +ith you?

K


41/50

s.*, if there is a )ause in my con/ersation, )lease understand that I am making a note. o

)lease dont hang u) the )hone.

(hat is your childs name? Is it a baby boy or a girl?

Ho+ old is your child?

(here is the child no+?Can you tell me more about your childs )roblem?

Fe/er:

!id you record the tem)erature? If yes, may I kno+ the reading? If no, is it lo+grade or high

grade?

Is it associated +ith any chills or rigors?

Is it associated +ith any s+eating?

!id you inter/ene in any manner? any medication like &ylenol?

4$&I:

!oes he ha/e any runny nose?

Any cough?

Any fast breathing?

Any ear discharge or ear )ulling? If yes, does he ha/e any hearing )roblem?Any +atering from eyes?

Any difficulty s+allo+ing?

$ash:does he ha/e any rash? If yes, +here and ho+ does it look like?

!iarrhea or /omiting:

Code O0CA''I!IO&

O-Onset,

0-number,

C-cry2cough2consistency,

A-associated sym)s-eg:4$&I sym)s,rash,etc.,

'-listlessness,'-li=uids-urine and intake out)ut,

I-immuni3ation,

!-diet,dehydration,de/elo)ment,daycare, doctor /isit

I-infections in family or ill contacts

O-O$

&-tra/el

"I&:stools-ho+ many stools does he )ass )er day?

Ho+ many soiled dia)ers do you change )er day?

!id u see any blood in it?!id u see any +orms in it?

(hats the color of the stools?(hats the consistency? +atery2semisolid;

Is it foul smelling?

!oes he cry +hile )assing stools?

!id he /omit or thro+ u)?

Is there any difficulty +ith s+allo+ing?

!id u notice any belly distension?

7


42/50

!oes the child seem to be ha/ing any belly )ain? like, does he hold his belly +hile crying?;

4rine:

did u notice any change in his urinary habits?

Ho+ many +et dia)ers do u change )er day?(hat is the color of the urine?

!oes he cry +hile )assing urine?

ei3ures:

!id u notice any shaky m/nts of the body?

!ehydration:

!id u notice any dry mouth or dry skin?

!id u notice any sunken eyes?

!id u notice any sunken soft head on his head?

Ho+ is his skin turgor? Is it moist or dry?

Acti/ities:

Can u tell me more about his acti/ities?!oes he look acti/e and )layful2dull and lethargic2irritable?

If dull, is he a+ake and res)onsi/e?

Food:(hat kind of food do u gi/e him?

Is there any change in his food recently?

Ho+ is his a))etite?

!id u notice any changes in his +eight?

A H 4 " F

& % I I ! # $ &-did he tra/el any+here recently? (as your child e/er in9ured?

%-birth history:0o+ I +ould like to ask you fe+ =s regarding little 9ohns birth.Is that ok +ith u?

!uring )regnancy;-did u smoke? !rink alcohol? 4se ilicit drugs during )regnancy?

!id u ha/e routine checku)s during )regnancy? Ho+ often?

!id you take 1& su))lements and /accine shots during )regnancy?!id u ha/e any com)lications during )regnancy? !eli/ery? Or after deli/ery?

(as you )regnancy full term? Or )reterm? Or delayed?

(as it a 01! or C?

After birth;-!id the baby cry after birth?(hen did u start breast feeding?

(hen did he )ass his2her first stool?(hen did he )ass his first urine?

!id he ha/e any medical )roblems after birth?

I-are all your childs immuni3ations2shots u)to date?

I-does he ha/e any ill contacts?

!-is your childs de/)tgro+th and height; in )ar +ith the children of same age?


43/50

!o you send him to daycare?

(hen +as his last doctors /isit? If yes, may I kno+ the reason?

#-ask for acti/ities =s

$-ask for any rash

-ho+ is his slee)?

FH:Are there any smokers around the child?

Is the child safe at home? child safety =s;- break the confidentiality and in/ol/e the child

safety team

Closure and ad/ice:

s.*, from the information you ha/e gi/en me, I am concerned that your childs fe/er maybe

due to infection in his u))er air+ays or lungs or bo+el acc to scenario;. Ho+e/er, it is /ery hard

for me to assess her o/er the tele)hone and I dont +ant to 9eo)ardi3e her health in any+ay.I

+ould like you to bring in your daughter2son to the medical center for a )hysical e6amination and

a full assessment. (e +ill then )roceed accordingly and at that time I +ill be in a better )osition

to tell you +hat e6actly is going on +ith your child.

ean+hile, )lease look for the +arning signs like- fe/er M7K


44/50

*E)E$ &ITH $(" OSE AD IC$EASED B$EATHI#

!2!: (orku):

1iral 4$&I hysical e6am

neumonia C%C +ith !C, electrolytesOtitis media %lood for C2, throat s+ab C2

e)ticemia neumatic otosco)yeningitis ' +ith o)ening )ressure and CF analysis

Occult bacteremia C*$

42A, C2

A(DICE

!!: (orku):

#arly onset P7+k- hysical e6amination

hysiological 9aundice C%C, #$, eleclyts,H%

%reast feeding 9aundice total bil, !% and I!%

A%O2$H incom)atibility %lood grou) and ty)ingLaundice of )rematurity !irect coombs test

0eonatal se)sisif mother had any infection or any ne+ born inf.; %lood for C2, C$

ce)halhematoma

Familial neonatal hy)erbilirubinemia

'ate onset M7+k-

%reast milk 9aundice

etabolic causes-hy)othyroidism, galactosemia

C2O discoloration

! O #Color changes:

(hen did you first notice it? P


45/50

!id u notice any belly distension?

%reast feeding:

Are u breast feeding the child?

(hen did you first breast feed your child?Ho+ often do you breast feed your child?

Ho+ long do you breast feed each time?Is he sucking +ell?

Is he also bottle fed? If yes, do you gi/e formula milk or co+s milk?

A%O incom)atibility:

(hat is your blood grou)? our husbands? our childs?

!id you become )regnant before? !id you ha/e any miscarriages?

!ehydration:

!id u notice any dry mouth or dry skin?

!id u notice any sunken eyes?

!id u notice any sunken soft head on his head?

Ho+ is his skin turgor? Is it moist or dry?

Acti/ities:

Can u tell me more about his acti/ities?

!oes he look acti/e and )layful2dull and lethargic2irritable?If dull, is he a+ake and res)onsi/e?

Fe/er:

!oes he ha/e any fe/er? Any shaky m/ts of his body? kernicterus;

!id you notice any rash on his body?

$O:

!oes he ha/e any runny nose? Cough? Fast breathing?!id you notice any ear discharge? #ar )ulling? (atering from eyes?

A H 4 "

A F F-acti/ity, feeding, sucking, family

Family-ho+ many siblings does little 6 ha/e? Ho+ are they doing? !o you send your children todaycare?

& % I I ! # $

&-did he tra/el any+here recently? (as your child e/er in9ured?

%-birth history:0o+ I +ould like to ask you fe+ =s regarding little 9ohns birth.Is that ok +ith u?

!uring )regnancy;-did u smoke? !rink alcohol? 4se ilicit drugs during )regnancy?

!id u ha/e routine checku)s during )regnancy? Ho+ often?

!id you take 1& su))lements and /accine shots during )regnancy?

!id u ha/e any com)lications during )regnancy? !eli/ery? Or after deli/ery?

(as you )regnancy full term? Or )reterm? Or delayed?

(as it a 01! or C?

After birth;-!id the baby cry after birth?

B


46/50

(hen did u start breast feeding?

(hen did he )ass his2her first stool?

(hen did he )ass his first urine?

!id he ha/e any medical )roblems after birth?

I-are all your childs immuni3ations2shots u)to date?

I-does he ha/e any ill contacts?

!-is your childs de/)tgro+th and height; in )ar +ith the children of same age?

!o you send him to daycare?

(hen +as his last doctors /isit? If yes, may I kno+ the reason?

Closure and ad/ice:

&hankyou for ans+ering all the =s )atiently. 0o+ I +ould like to summari3e +hat you ha/e told

me.

After summary-ask is that all or do you +ant me to add anything to this?

0o+ I +ould like to gi/e my im)ression:%ased on the information gi/e by you, I think your childs )roblem could be due to )hysiological

9aundice, +hich is a natural condition seen in infants and gradually disa))ears by 7 to < +ks.

Ho+e/er, there are also other )ossibilities like 9aundice due to breast feeding or blood grou)

mismatch or birth defects or some other )athological conditions +hich needs to be ruled out.

Ho+e/er, it is /ery hard for me to assess her o/er the tele)hone and I dont +ant to 9eo)ardi3e

her health in any+ay. I +ould like you to bring in your daughter2son to the medical center for a

)hysical e6amination and a full assessment. (e +ill then )roceed accordingly and at that time I

+ill be in a better )osition to tell you +hat e6actly is going on +ith your child.

ean+hile, )lease look for the +arning signs like- fe/er M7K


47/50

ST$IDO$

!!: code FC'#A$

Foreign body obstruction

Crou)'aryngitis, laryngomalacia

#)iglottitisAngioedema

$etro)haryngeal abscess

(orku):

hysical e6am

A%" analysis

C%C

*ray neckA and lateral;

C*$ A /ie+ in e6)iration;

!irect laryngosco)y and bronchosco)y

Child in #$:I am really /ery sorry that your child is in #$. I can understand that you are /ery an6ious about

your childs health, but donot +orry, your child is in safe hands. (e ha/e a /ery good intensi/e

care team at our hos)ital +ho +ill take care of your child /ery +ell. our emotional stability is

/ery im)ortant for your childs health, )lease be strong.&o kno+ more about your childs )roblem, I +ould like to ask you fe+ =s and +rite do+n notes

+hile +e talk. I assure you that I +ill be as =uick as )ossible. o )lease bear +ith me for some

time. As soon as I am done +ith my =s, I +ill go and e6amine your child )ersonally. Is that ok

+ith you? hall I )roceed?

Ok s.*, I am !r.$a/i the attending )ediatrician at this medical center and I +ill be taking care

of your child today555555

(hat is your childs name? ho+ old is he2she?ay I kno+ +hy is he in the IC4?

other gi/es com)laint55..

ho+ em)athy5555..

Can you tell me more about your childs )roblem?

! O # F A A#-+hat +as he doing +hen it started?

F-is the sound consistently there or does it come and go?

Associated =s:Code %I"!CH

%-+hen is it better heard? (hile breathing in or out? Is there any breathlessness? Any bluishdiscoloration?

I-did you inter/ene in any +ay? Any h2o intubation?

"-guraka-does he snore +hile slee)ing?

!-any drooling or difficulty in s+allo+ing?

C-any cry or cough?

H-any hoarseness?

D


48/50

Ask for &%I!!#$:

%irth, immuni3ation, diet, daycare, de/elo)ment, doctor /isit

Ask for any rash and s+elling of face-hereditary angioedema;

Closure and ad/ice:If its a )hone case-s.6, according to the information gi/en by you, I am considering a

)ossibility of foreign body as)iration. Ho+e/er, there are se/eral other )ossibilities that need to

be ruled out and I feel that she needs emergency medical attention. o I suggest you to call 77

immediately and bring her to the medical center.

ean+hile, I ad/ice you not to attem)t to remo/e the foreign body because this may cause it to

become more dee)ly lodged, if it is actually )resent.

In case, if you notice any choking or res)iratory com)romise, )lease )erform a heimlichs

maneu/er by thrusting tummy +ith sudden )ressure.

PIC1" EATE$

!!:

Habitual eating disorder'o+ fiber diet

'ead )oisioning

Iron deficiency anemia

arasitic infestation

Hy)othyroidism

O))osition defiant disorder

A!H!

(orku):

hysical e6am

C%C, serum electrolytes

erum lead le/els

tool for o/a and )arasites

erum &Herum iron studies

Hello, I am !r.$a/i. I am the attending )ediatrician a this medical center. ay I kno+ +ith +hom

I am talking to?(hat is your relationshi) +ith the child?

Its nice to talk to you. Ho+ can I hel) you?he gi/es the com)laints5555..

I am sorry to hear that s.6. I +ill try my best to hel) you out in this regard555..

(hat is your childs name? Ho+ old is he?

(here is he? (hat is he doing no+?

(hy do you think he is a )icky eater?

!oes he ha/e any s)ecific )references for the food?

E


49/50

! O # F since ho+ long has he been ha/ing this )roblem? Ho+ it is )rogressing?is it getting

+orse or getting better?; does he constantly beha/e like that? ho+ fre=uently does he eat?

%eha/ior:

Ha/e you e/er )unished or re+arded your child to alter his eating beha/ior?!oes he +atch t/ +hile eating?

!oes he follo+ his schedule of meals?!oes he often drink high calorie drinks like sodas, 9uice or milk?

!o you offer any desserts +ith regular meals?

%o+els:

!oes he ha/e any belly )ain?

Any )roblems +ith bo+el m/ts? If yes, ho+ many times a +eek does he ha/e his bo+el m/ts? if

P> stools )er +eekconsti)ation. If for Myrs;

Ho+ long does he sit on the toilet?

!oes he resist toilet training?

!oes he a/oid toilet because of acti/ities such as )laying?

Family:

Ho+ many children do you ha/e?

Ho+ much time do you s)end +ith them?

(ho takes care of them +hen you are +orking?

!oes he go to daycare? If yes, does he ha/e any ill contacts there?

Ask for any other associated sym)s: 4$&I, diarrhea sym)s

'ead )oisioning- +hat kind of house do you li/e in?/ery old one?;

&em)er tantrum /s. A!H!:

Is the child easily distractable?

!oes he ha/e any difficulty +ith conc and focus?

Ho+ is his memory?!oes he ha/e any )roblems organi3ing ideas and belongings?

!oes he sho+ any im)ulsity?

!oes he ha/e +eak )lanning and e6ecution?

& % I I ! # $

A H 4 " F

Closure and ad/ice:

rs.*, According to the information you )ro/ided me, I feel that your son is )robably )assing

through a normal )hase of gro+th. It is a common )roblem in this age grou). Fortunately, it

res)onds +ell to a fe+ beha/ioral changes.

First of all, I +ould suggest you to strictly follo+ a set schedule and offer him /ariety of foods at

meal time.


50/50

!iscourage high calorie drinks b2+ meals

0e6t im)ortant thing is en/ironment at meal time. It should be )leasant +ithout any distractions.

Any argument or +atching t/ should be a/oided at the same time.

$egarding the consti)ation, I +ould suggest you to )ro/ide him high fiber diet like cereals and

/egetables. #ncourage him to follo+ a scheduled time to sit on the toilet by re+arding him.Ho+e/er, I need to e6amine him )ersonally and run do+n some tests to rule out some other

)ossible causes of consti)ation and beha/ioral disorders before I make a definiti/e diagnosis andgi/e you my o)inion.

!oes that sound good to you?

I ho)e you understand +hat +e discussed today.

!o you ha/e any =uestions for me?

Ok then, I +ill be looking for+ard to see you at the hos)ital. &ake care and bye bye.

EE($ESIS

step2 cs notes

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