Osce, Basel (2)

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45 Y/O male/chest pain for the last 3 days/ ER/ HX Acute chest pain: •

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1-3 hours  heart attack, unstable angina (NSEMI), aortic dissection, pneumothorax (last for minute to hour, otherwise he will die!) First attack of GERD, diffuse spasm, trauma to chest. 3 days chest pain: o continuous: 1. Heart: Pericarditis 2. Lung: PE (based on size presentation could be different. 3. Chest wall: herpes zoster trauma to chest (musculoskeletal). 4. (Gastric cancer #10 in your list.) o Intermittent

CC OCD PQRSTAA (and is it the first time?) Associated symptoms (with the transition) • •

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Cardiac By system or by differential diagnosis ( pulmonary, GI, pericarditis Risk Factors: cardiac (5), pericarditis (renal failure, recent heart attack, recent surgery, recent flu, malignancy, medication (TB),) pulmonary (recent travel, malignancy, CHF, ocp (for women)

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Knock, knock, knock Introduction: As I understand, you are here because you have been having severe chest pain for the last three days, can you tell me more about that from the moment it started? - How did it start? Gradually - What were you doing at that time? I can’t remember. - Is it all the time or on and off? It’s all the time. - Is it increasing or decreasing? It’s increasing. - I can see you are in a lot of pain, bare with me for just a few minutes and then I’ll give you some painkiller. - Is this the first time? Yes. - How do you feel it? Stabbing. - Does it shoot anywhere? No. - On the scale from zero (which would be no pain) to ten (which is the worst pain you have ever experienced), where do you put your pain? - Where you able to sleep last night? No. - It must have been difficult, I’m glad you came here; hopefully we can figure out what’s going on. - Is there anything that increasing or decreasing it like breathing or leaning forward? Did you try any medications? - In addition to this, did you notice any other symptoms?

Constitutional symptoms: Any fever, chills, lumps and bumps, loss of appetite, weight loss, history of cancer?

Cardiac: Any Nausea, vomiting, excessive sweating, loss of consciousness, dizziness, heart racing?

Lung: Any cough, phlegm, shortness of breath, wheezing, chest tightness, coughing blood, recent flu like syndrome fever, night sweat?

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GI: Any heart burn, difficulty swallowing, acid taste in your mouth history of peptic ulcer?

DVT: Any recent trauma, redness and swelling in your legs, pain in calf, recent travel, prolonged staying in a position? - Now I’m going to ask about factors that might put you at risk: (Even though it looks like pericarditis, you still need to go for cardiac risk factors because you don’t want to lose anything.) Cardiac: major (high blood sugar, high blood pressure, stress, diet, positive family history) Pericarditis: ……. -And also pass medical history, family history and social history.

“A dream doesn’t become a reality through magic; it takes sweat, determination and hard work” COLIN POWELL

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45 Y/O male/ chest pain for the last 6 weeks/ ER/ HX/ 5 min

Intermittent chest pain: 1. 2. 3. 4.

Cardiac: stable Angina, unstable Angina Pulmonary: __ GI: GERD, DES (diffuse oesophageal spasm Panic attack: (patient can remember exactly how many episodes he had)

KKK -As I understand you are here because you had chest pain for the last 6 weeks. Can you tell me more about it? P: Yes, I’ve been having the pain for the last 6 weeks. It increased gradually, I’m concerned about it. -I see, what is your concern? P: I started to have it at night. -How about now, do you feel any pain right now? (Whenever patient says “I’m concerned” or “worried”, you should say “I can see you are concerned, what is your concern? Do you need any information? Are you interested in general information, or do you need any specific information?”) -How did it start? Gradually. -What were you doing? P: I was playing golf. (Playing golf has two important points. One would be because of the physical activity he’s doing; that might cause or aggravate chest pain, and the other would be bending during golf that might cause GERD.) -Is it increasing or decreasing? -Is this the first time you have these symptoms? -From that time until now, is the pain all the time or is it on and off? P: It’s on and off. -How often do you have it?

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-How many attacks have you had in the last week? (Frequency), how many in the beginning? -Are these attacks, similar to the earlier ones? -Are they more severe than before? How many blocks can you walk now? How many could you walk then? (What about having meal?) -Can you show me where exactly the pain is? How does it feel like? Squeezing. -Does it shoot anywhere? My jaw. -How about your shoulder, hand, and back? - On the scale from zero (which would be no pain) to ten (which is the worst pain you have ever experienced), where do you put your pain? -Is it in a particular time of the day? How about night? -Is it related to activities, heavy meals, stress, breathing, cold air, change in position? -Is there anything that increases or decreases your pain?

Constitutional Sx: Any fever, chills, lumps and bumps, loss of appetite, weight loss, history of cancer?

Cardiac: Any Nausea, vomiting, excessive sweating, loss of consciousness, dizziness, heart racing?

Lung: Any cough, phlegm, shortness of breath, wheezing, chest tightness, coughing blood, recent flu like syndrome fever, night sweat?

GI: Any heart burn, difficulty swallowing, acid taste in your mouth history of peptic ulcer?

CHF symptom: leg swelling, S.O.B, how many pillow do you put under your head

Panic attack symptoms: excessive fear? sense of losing control, death or being crazy.

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Risk Factors: -Because it is the first time I see you, I would like to ask some questions to see if there is any conditions that might explain your symptoms. -Any history of high blood sugar, high blood pressure, high cholesterol, stress, and positive family history for heart disease? -When is it diagnosed? Is it controlled? -Do you smoke? How much and for how long? -Have you ever considered quitting? (You have to be nonjudgmental.) -I would like you to know smoking is harmful to your body, if you would like to, we can arrange a meeting to help you quit. (And also past medical history, family history and social history).

“One important key to success is self-confidence.an important key to self-confidence is preparation” . ARTHUR ASHE

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42y/o chest pain for the last 6 weeks/HX and counselling/clinic Introduction -As I understand you are here because you have been having chest pain for the last 6 weeks, during the next few minutes, I’ll take history, do some physical exams and hopefully toward the end of our session, we’ll reach our working plan. -During the exam I might take some notes, is that okay with you? Do you have any questions at this start? -When did your pain start? P:It started 6 weeks ago and it’s improving and I’m very concerned. -What is your concern? P: My dad died from heart disease in age 45. -It is a very reasonable concern, I’m glad you came here. Hopefully we can figure it out together and deal with it. -How did it start and how long did it last? P:It started suddenly and lasted for a few hours. -Is it increasing or decreasing? P: It’s almost the same as the beginning. - From that time until now, is the pain all the time or is it on and off? P: It’s on and off. - How long do they last? How about beginning? -How often do you have it? -How does it feel? __ (patient refuse to answer this question) -Does it shoot anywhere? - On the scale from zero (which would be no pain) to ten (which is the worst pain you have ever experienced), where do you put your pain? P: Sometimes 5, sometimes10.

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-Does it decrease or increase with exercises or changing positions? -How did it affect your life, how did it affect you financially? You can refer the patient to social worker. -Is there anything that makes it better or worse?

Cardiac: Any Nausea, vomiting, excessive sweating, loss of consciousness, dizziness, heart racing? Lung: Any cough, phlegm, shortness of breath, wheezing, chest tightness, coughing blood, recent flu like syndrome fever, night sweat? GI: Any heart burn, difficulty swallowing, acid taste in your mouth history of peptic ulcer? Is there something new? Risk Factors: Cardiac: (5), CHF, GERD (repeated cough, change in voice, tight clothing position, diet triggers; like alcohol, chocolate, fat, obesity pregnancy and strogen. PMH, FHX, SHX.

Counselling: -I know you are here because you are concerned because of heart disease, this is quite reasonable to be worried about, as I told you. Based on what we have done so far, the chance of having heart disease is low but because of smoking, positive family history, and diet, we still need to rule it out completely by doing some blood work, electrical tracing of your heart. Even -If they are normal, we still can’t send you for more confirmatory assessments, such as exercise test to be sure (EST), on the other hand, most likely your pain can be explained by a common condition called GERD. Have you ever heard of it? It stands for: Gastroesphageal Reflux Disease (always in concealing you should give the patient the name of the condition, then simply explain pathophysiology and mechanism of the disease. Then talk about how to treat it and side effects of the treatment, and then mention about alternative option and complication of not treating.) -When you eat food, it goes down through your feeding tube, or food pipe. In the lower part of your oesophagus is stomach which contains acid. There is a valve like structure between these two which prevent going acid up from stomach to oesophagus. In GERD, this acid leaks up and causes pain. What we 8

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are trying to do is preventing that from happening. It is a common condition that can be treated by modification of the risk factors. -Is it reasonable? Wait control is important; I can refer you to a dietician. You need three meals and three snacks and also try to avoid having meals late before sleep and avoid these specific foods like alcohol, chocolate, avoid tight clothing and ….. It is also a good idea to raise the head of your bed about 6 inches (10 cm). Quitting in smoking is also important because you have been having symptoms while sleeping; it is a good idea to start some medication for you (proton pumps inhibitor). You have to take it for one month and we will see how it affects you. There is also some articles and brochures available here.

“Open your arms to change, but don’t go of your values

”DALAI LAMA

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28 Y/O chest pain for the last 6 weeks ER/ HX+ counselling

Differential diagnosis: cardiac, GI, pulmonary, panic attack Introduction As I understand ………. P:Yes Dr. I have been having chest pain for the last 6 week. OCD, PQRSTAA How did it start? Suddenly What were you doing in that time? nothing How many attack did you have? Three Dose it shoot anywhere? Are they the same or not? How does it feel? Not specific On the scale from 1-10……….? 5-7, variable. Any increasing or decreasing factors? Not really P:I am very concerned about that. I’m afraid from having another attack

Associated symptom: Cardiac: nausea+, vomiting, sweating+, dizziness+, heart racing+, loss of consciousness.

Lung: SOB+, cough, whizzing, chest tightness. GI: difficulty swallowing+ (sense of lump in chest), heart burn. Neurologic: shakiness+, numbness, weakness, light headedness+, sense of losing control or going crazy+. -Do you feel that things around you are not real? -Can you see yourself from outside from the attack? -Sometimes whenever people have similar chest pain may lose control or feel that they’re going crazy or dying. Have you experienced it?

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-Is there anything that brings these attacks? -Are you under stress? What kind of stress? How do you cope with it?

Co-morbidity: GAD, OCD, PTSD, Phobia -Are you such a person that is worried a lot? -Any fear from being in high places, or certain objects, or animals, or speaking in public (specific phobia)? -Do you have repetitive intrusive thought that you feel you are not able to get rid of them (OCD)? -Have you ever experienced in which personal and emotional safety and wellbeing is in danger? -Any thinking, nightmares, flash backs about that? -At that time, did you have tense period of sever fear for which you lose your control?

MOAPSS: (mood, organic, anxiety, psychosis, selfcare,suicide) Ask PMH in organic: any long term dis, MVP, hyperthyroidism, drugs like cocaine……….

Counselling: Based on what you have told me, your chest pain is most likely related to a medical condition called panic attack. It’s a common condition related to stress.

Explanation: Imagine you are crossing a street and there is a car approaching you fast. How would you feel? At that time, you would feel afraid and your heart would go fast and your blood pressure would increase and you would be more alert and it is very important because it helps you to deal with a danger situation and this is related to a hormone called Norepinephrine. Sometimes the same reaction might happen without any trigger and obvious risk which is panic attack. More than half of people will improve. We have different treatment options; I can refer you to a psychiatrist …

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We have 2 kinds of medications, first we start with benzodiazepine for the first 2 weeks. At the same time, we start other types of medication called SSRIs for 6 months. They are safe but because of some side effects, like abdominal discomfort, nausea dizziness, we increase it gradually. (In some patients improvement of energy might be faster than improvement of mood and it is important for those who have suicidal thought .in this situation they are told to contact their physician) (Beside we need to do PE and some lab test like TSH,……….)

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71Y/O female/Abdominal pain for the last 4 weeks Abdominal pain Related to meal: mesenteric ischemia ,Ischemic colitis, gastric cancer, pancreatic failure(bulky stool, shooting to back),GERD, cholecystitis Introduction As I understand…………………… Patient is concern about having stomach cancer because his wife has died from stomach cancer. When was that? How do you feel about that? It is good you came here, now we can find what is the cause of your pain. Usually stomach cancer is not similar to flu; we don’t get it by infection. It’s related to food and the other risk factors but because you have been together for years, you have exposed to the same environment and some underlying risk factors. OCD PQRSTAA(increasing gradually-on and off-dull wage pain-no shooting) Is it related to anything? Any specific time in the day? Any nausea, vomiting pain after meal, change in bowel movement? Did you lose weight? Constitutional symptom

Risk factors: for ischemic colitis: DM,HTN,FHX of heart disease (what kind? when? Are you under regular follow up? when was your last f/u visit? any intervention? Any treatment? any trigger? (And For peptic ulcer and gastric cancer)

Wrap up: I know you are here because you have concern about abdominal pain, however cardiac symptoms are concerning for me. I am going to do PE and some blood works and ECG to find any underlying heart disease and also I’ll do surgical and cardiac consultation.

“Control your own destiny or someone else will.” 13

JACK WELCH

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45y/o male /leg pain for the last10week/clinic/HX Intermittent claudication: 1. Neurologic (increase pain when going down hills.) 2. Vascular (related to time, and increase going uphill.) OCD PQRST AA Local symptoms Risk Factors: 1. Cardiac 2. Neurologic, spinal PMH, FH, SH As I understand you are here …. -Is the pain in one side or both? -Did you seek any medical attention? -What makes you to choose to come today? My pain started last night. -What were you doing at that time? -How often do you have it? -How long does it last each time? -What does bring the pain up? Is it related to any activities? -How many blocks can you walk? (How many now? What about before?) -What do you do when you have pain? -Do you have pain at rest? How about if you dangled your feet? -Have you ever wake up with this pain? (Alarming) PQRST AA -How does it feel? Crabs. -Do you have pain in your toes, foot, thigh, buttocks? (Lerish syndromeid )

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-Did you notice you have you have more pain when you walk uphill or downhill? Does it make any difference? -Is it related to time or related to the way you seat? Local symptoms: In addition to your pain, do you have any numbness, tingling, weakness, burning sensation? -Any color change, ulcer, hair loss, thickening of your nails, coldness? Back pain, back trauma Constitutional symptoms: ... Risk Factors: DM, HTN, high cholesterol, heart disease, smoking, medication (b-blocker), HX of peripheral vascular disease

-Sometimes some patients who have this pain, might note change in sexual desire or any difficulty with erection. What about you? (If you have still time, check symptoms of heart and mesenteric ischemia) -How did it affect your life? -I’m glad you came here today, we will do further steps to be sure.(ultrasound) I’ll give you a medical note for your work to modify your job.

“In order for you to succeed, your desire for success should be greater” Than your fear of failure”. BILL COSBY

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67 Y/O/fall 20 minutes ago/ER/10 min/HX & concealing

Introduction Every time the patient had loss of consciousness you plan for event. Event (fall):

- Before -During - After

Causes:

Medication (poly pharmacy) Recent hypovolemia (decrease in take, recent bleeding, vomiting Diarrhea

PMH, FHx, Social history

4 setting in which you ask the patient “how do you feel right now?” 1) After the fall (did you hurt yourself? Does it still hurt? I’m going to take a look after I finish my interview.) 2) The patient who couldn’t pass urine (Bear with me just for a few minutes, I will bring a surgeon to put a catheter for you.) 3) Hypoglycaemia and Arrhythmia (you are fine, I’m looking after you) 4) The patient who attempt suicide.

-As I understand, you are here because you had fell 20 minutes ago. Before I proceed, I’d like to ask you about how you feel right now. -Did you hurt yourself? -Can you tell me more about what happened?

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-Did you lose your consciousness? Yes, I was having a nap, when I woke up, I fell down on the floor. -Where you alone? No, I was with my wife. -Did she accompany you? -Did she describe what happened to you? -If you don’t mind, after we finish, I’m going to clarify some point. -Before you fell down, did you feel any dizziness or light-headedness? Any sense of spinning things around you? -Did you fall down immediately, or were you able to take some steps? -Before you fell down, did you feel hungry, heart racing, shakiness, sweating? (Hypoglycaemia) -Any chest pain or heart racing? (ischemia- arrhythmia) -Any weakness, numbness, difficulty finding words, change or loss of vision? (CVA) -Any flashes, light, strange feeling? (Seizure) -How long were you unconscious? -How did you regain consciousness? On your own or after intervention? (Hypoglycaemia) -While you were unconscious, did your wife mention, if you were shaking or jerking moment? (One part, or all over the body? Did you bite your tongue, rolled up your eyes? Did you hurt yourself? Was there any loss in bladder, or bowel control? Where you breathing? Did you turn blue (seriousness)? After you gained your consciousness did you feel things around you are not familiar? (confusion) -I’m going to ask more questions to see what would be the cause of your fall. -Do you take any medication? Do you have the list? Metformin, B- blocker, hydrochlorothiazide, Lipitor, ASA, B Complex, B12, benzodiazepine, Amitriptyline. Ask about them one by one in Q2 exam and any recent change in medication in CE1 exam. Metformin: When did you diagnose by DM?

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How controlled where you? When was the last time you saw your doctor? Do you measure your blood sugar? Are you taking water pills? How long and why? Any new change in dose? Why do you take b-blocker? For how long? Why are you taking ASA? By prescription or on your own? Have you had recent bleeding? You are taking two sleeping pills. Are they per scripted by the same doctor or a different doctor? Any recent change in dose? What about amitriptyline? Are you depressed? How long are you taking it? Do you think about hurting yourself or the others? Patient: I didn’t feel so good, so my doctor increased the dose of Amitriptyline. Did you have any diarrhoea bleeding, vomiting, …? Constitutional symptoms, PMH, FHX, social HX. ( PE, was done  orthostatic hypotension) Based on what you told me, most likely the reason of your fall is a condition called orthostatic or postural hypotension. Have you ever heard about that? Whenever we change our position from lying to sitting, or sitting to standing, the blood tends to pool in our legs. Usually, our body reacts to it by narrowing blood vessels to maintain blood pressure. Sometimes because of age, medication , diabetes or combination of the body fail to react appropriately so the blood pressure drops and fails to reache to brain. This condition may happen again so whenever you want to change your position, do it slowly or sit on the edge of the bed, also I would like to contact your psychiatrist in order to see if he wants to change the medication or adjust the dosage. Also ECG?

Life just does not hand you things. You have to get out there and make things happen. EMERIL LAGASSE 18

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Heart racing Case: male patient 37 years old, having palpitation for the last six weeks. Hx and counselling Consequences of Atrial fibrillation: embolism, sudden death, heart failure Cause: age, coronary arty disease, valvular heart disease, heart failure, hyperthyroidism in old patients, alcohol (holiday heart), lone AF ( only one time in 24 hours), COPD, medication ( digoxin), cocaine, any factor gives tachycardia in right setting ( anaemia, ephedrine, chocolate, coffee, antihistamine, decrease volume, beta agonist), any factor give enlargement of the heart Differential diagnosis: pheochromocytoma, hyperthyroidism, panic attack Ask Sudden death in the family: 1. Hypertrophic cardiomyopathy 2. QT prolongation Once the AF became continuous (48 H) the possibility of clot formation became high so we should ask to screen neurological problems: do you have difficulty finding words? Any weakness, numbness in your body?

KKKKKKKKKKK

Dr: Good afternoon, Mr. Douglas, I’m Dr. Miller one of the physician working in the clinic today. As i understand you are here because you have palpitation for the last six weeks, could you tell me more about it? P: it is not improving and I’m getting concern about it. Dr: what kind of concern? P: I have never had it before, I’m not sure is it serous or not. (Whenever patient uses medical term we should clarify to make sure we are in the same line) Dr: before I proceed I’d like to know, when you say palpitation what do you mean?

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(The patient might say my heart skipping beats or going fast, or my heart is bouncing in my chest) P: my heart goes fast Dr: how did it start? P: I started suddenly Dr: what were you doing? How long did it last at that time? From that time till now, is it all the time or on and off? P: in the last 3 weeks it started became continuous and at the beginning it was attacks. Dr: before that how often did you have it? What was the duration of these attacks? What was the duration of the longest attack? Did you have any attack longer than 48 hours? Dr: even during the night? How did it affect your sleep? (Because it is more than 24 hours we empathize with the patient) Dr. Can you tap it for me? Dr: it sounds irregular to me. Dr: is it the first time or did it happen before? P: no, it didn’t happen before. Dr: with that did you notice any chest pain, chest tightness, any dizziness, light headedness, or loss of consciousness, sweating, nausea vomiting (cardiac symptoms) (Because it is long and irregular and day and night it is not panic it attack.) Dr: Did you notice anything increase it? Anything decrease it? Anything brings it? Do you believe it related to coffee, chocolate, energy drinks, alcohol? Do you smoke (for extrasystoly) have you ever try recreational drugs (cocaine can cause arrhythmia)? (If the patient says I fell I’m dying and it is scary we can say as empathy: sometimes people feel like that with heart racing and I know that it is very scary) Transition: I’m going to ask you more questions to see what could be the cause.

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Dr: Do you have history of heart disease? Any history of thyroid disease? If you are in a place that everybody feels fine, do you feel hot? Do you have any weight loss and any shakiness? Do you have moist skin? Anybody told you are pale? Any bleeding recently? Have you ever been diagnosed with romatic fever? (if no) as a child did you have repeated attacks of sore throat? (if no) do you remember injection of penicillin or any antibiotic on regular basis? P: yes, but I had allergy and they stopped it. Dr: any repeated attacks of headache with the heart racing and excessive sweating? (pheo) Dr: any diarrhoea? Flushing? (characinoid) Any family history of sudden death at young age? Do you take medication? Have you ever been seen by a psychiatrics? In the last few weeks did you notice any difficulty finding words, weakness, numbness in your body? Transition: as this is the first time I see you, any long term disease? Any high blood pressure? High blood sugar? Hospitalization. How do you support yourself? Stress? In the Ph.Ex don’t forget to tilt for mitral stenosis, use bell. Ph.Ex: general exam, vitals, touch thyroid, cardiac exam, if have time neurological system.

Dizziness: 1. Panic attack 2. In older person deal with it as syncope, is it repeated or one time a. repeated: is it related to cough, urination, or emotional stress, vasovagal b. once: is it related to change in position ( exclude everything related to event), medication, cardiac, neurologic, spinning

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General Physical Exam lessons: Cardiovascular exam: Introduction, Vitals, inspection (general and specific), then palpation, then auscultation with 2 accentuating manoeuvres: sitting up and holding breath and in&out, bending forward. Then you go for peripheral related exams like JVP exam, finger nails. Respiratory system: Introduction, Vitals, Inspection, palpation and feeling, tapping or percussion for resonance and dullness, auscultation and special tests (say 99, vocal and tactile fremitus, ego phony and whispered pectoroliqouy) GI system: inspection, AUSCULTATION, percussion, superficial and deep palpation, some special tests like Mcburny and Row sing’s sign, DRE and pelvic exam. MSK system: Introduction, Vitals, Inspection (SEADS: swelling, erythema, atrophy, deformity, scars), and palpation (TTC: tenderness, temperature, crepitus) Range of movement: active, passive and against resistance. In neck, back and hand do neurovascular. Shoulder mostly mechanical and knee mostly stability. Ankylosing spondylitis mostly mechanical. One joint above one below. Neurologic exam: Introduction, Vitals, Inspection and orientation, Cranial nerves, upper and lower extremities, Coordination and gait and dysdiadocokinesia, end up with cortical sensation. Muscular exam: inspection, bulk, tone, power, reflexes and sensory. 5 feet: 150cm, 6 feet: 180, 5`6: 165, 220:100kg Do SEADS for all joints.

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HAND TREMOR EXAM: Hello, Good afternoon, Mr. Andros, I am Dr. Miller, one of the physicians working in this clinic today. As I understand you are here, because you have shakiness in your right hand. I have been asked to do a Physical examination, if you had any questions, Please do not hesitate to ask me. If you want to do the V/S at the moment, it is fine, otherwise skip over it. Do not forget to ask about orthostatic hypotension (Parkinson disease). 1. Ask the patient to count from 10 to 1. The tremor did not disappear (even increased) which is consistent with Parkinson and rules out anxiety. 2. There is no fine tremors (rule out hyperthyroidism), 3. No flapping tremor(R/O liver and other internal organ failure). 4. Touch your nose and my finger repeatedly with arm change(R/O intentional tremor in cerebellar diseases). 5. Essential tremor is all the time and disappears with B-blockers or a shot of whisky and is familial. In inspection the patient has tremor in his right hand and right arm and the patient does not have tremor in the left arm and if there is any pill rolling or head nodding, mention it. There is cog wheeling in the right arm and wrist and elbow, there is fine rigidity, I cannot assist any spasticity because the patient is rigid. There is no rigidity, spasticity, cog wheeling on the left side. Now ask the patient to stand up, the patient has difficulty in initiating movement, having stooped posture, festinating gait, ask him to turn in blocks. Pull the patient to the back (in Parkinson they continue to fall down and cannot control themselves). Come and sit: check for mask face, decreased eye blinking and drooling, monotonous speech, articulation (normal or abnormal) micrographia and check for dysdiadokokynesia. 2

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ACUTE BACK PAIN EXAM: Hello, good afternoon, Mr. Douglas, I am Dr. Miller, one of the physicians working in this clinic today, As I understand you are here because of the back pain for the last three days, and I have been asked to do a physical exam and ask some questions about it. During my exam if you had any pain or discomfort, or any other concerns to stop, please do not hesitate to inform me. Do you prefer to be lying down or to be standing? How did it start?

Standing.

3 days ago I was lifting an object heavier than usual.

How was the pain?

Stabbing.

Were you able to continue?

No. I had to stop.

From that time is it all the time or on and off? Increasing or decreasing? At certain time of the day? Can you point or show me where your pain is? How does it feel?

A sharp pain in my back.

Does it shoot to anywhere? Both or one?

Yes, to my leg.

No, to the right one.

Which one bothers you more, your back or your leg? How is the severity of the pain if you want to grade it from 1 to 10? 7. That was very difficult I could not even sleep. Did you take any painkiller? Good you are here, hope we would be able to deal with that and help you. Anything that increase your pain? How about lying down, stretching your back, bending or moving? Is it the first time you have such a problem? In addition to your back pain, do you have any numbness, tingling? Any difficulty with your balance, any falls? Difficulty with passing urine or loss of control? Bowel movement? Any numbness in the buttocks? Any fever, night sweat, chills? Loss of appetite? Weight loss? Any trauma to your back? Smoke drink, drugs? 3

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Long term diseases? Surgery? Burning sensation with urine? How did this affect you? How do you support yourself financially? Now I start the P/E, can you tell me the vitals please? Turn the patient to the way examiner can see. May I untie your gown? Normal cervical and thoracic curvature. No scoliosis, scars, atrophy. Feel your back, normal temperature. I am going to press now. I reach lumbar area, if you have any pain please inform me. Do some movements for me please. Try to bend as much as you can. Can you touch your toe with your fingers? Bend right and left. Can you cross your arms? Walk towards the wall (hold your arms around him in order not to fall). Walk on your heels. He can. And on your toes, he will not be able to do it  There is normal L5 and impairment of S1. (Heel#L5, Toe#S1) Please lie down. Do you need my help? I am going to raise your leg, which might cause some pain, please inform me. (SLR test) Then I go to the sensory, I am going to touch different parts of your toes: Little toe: S1, Big toe (first web): L5, middle malleolous: L4, knee: L3, Mid Thigh: L2. Then check the powers. Next step: Just relax. I want to check your reflexes, first the Knee, then the Achilles, you mention but do not do the Babinsky. To examiner: I would like to do DRE. End up with the pulses.

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CHRONIC BACK PAIN: Hello, Good afternoon, Mr. Anderson, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here due to the back pain since the last six months. I have been asked to do the physical exam. During my exam at any time if you had any pain discomfort or questions, please do not hesitate to ask me, also I will report my findings to the examiner, is that OK with you? Can you tell me the Vitals, please? The patient is sitting comfortably with no signs of distress. Would you please stand up? If I wanted to do the history first or doing the physical exam of the Ankylosing spondylitis, I would have started with my inspection (may I untie your gown?). Do you need my help? From the side NL cervical and thoracic and lumbar curvature, no obvious scoliosis from the back view. No signs of scar, swelling, deformity or oedema, also no obvious muscle contraction. I warm my hands. I am going to feel your back. NL temperature. I am pressing on the spine. Always identify C7 spinous process, then thoracic spine and lumbar area. Feel paravertebral muscles. Since it is chronic back pain, do Sacroiliac joints. I’d like you to do some movements for me: 1. Can you touch your toes with your fingers without bending your knees? (Limited flexion) 2. Can you arch your back? Can you bend to the right and left laterals? 3. Can you slide your arm along your side? 4. Can you cross your arms?

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I am going to do a special test called Shober’s test: I am going to draw some lines on your back, which are washable: Line 1: at the level of Sacroiliac joint and line: 2, 10 cm above it. Try to touch your toes. The distance of 10 cm should increase to 15 cm or more. Stand in front of the wall and touch the wall with back of your head, shoulders, hips and heels. Then please walk. NL gait is seen. Walk on your toes: NL S1, Walk on your heels: NL L5. I want to look at your eyes; there is no redness, pallor or yellowish discoloration of sclera. Ankle reflex is NL  S1. Open your mouth, no ulcers. I am going to take a look at your hands No pitting changes in the nails. No clubbing, no psoriatic changes or skin rash. Would you please lie down? Cover him. Do SLR. Do Patrick’s test. Listen to his heart for murmur or regurgitation. Then mention digital rectal exam. If time is left, mention power and sensory, too. Do the chest expansion test.

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Neck pain exam (short introduction): Hello, good afternoon, Mr. Douglas, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here because of the neck pain for the last two weeks, and I have been asked to do a physical exam. During my exam if you had any pain or discomfort, or any other concerns to stop, please do not hesitate to inform me. Taking the vitals. Based on the vitals, the patient is stable and I am going to proceed (report any abnormality in the vitals). (If they don’t provide you the vitals you have to do them. If they don’t give you even 1 of them you have to ask for it). The patient is sitting comfortable without any signs of distress. Go to the back of the patient. I want to have a look at your neck. May I untie your gown? Normal cervical and thoracic curvature from the side. No scars, or deformity, muscular atrophy or swelling or erythema. Warm the hands. I am going to feel: 1. Temp. Is Nl. 2. Feel the vertebrae, spinous processes till the middle of the thoracic spines? 3. Feel Para vertebral muscles. 4. Feel and exam Trapezius and Sternocleidomastoid muscle. 5. Then feel the mastoid process. 6. Then check for the lymph nodes. I want to feel the back, if you had any pain, please inform me. Cervical spines are not tender. I’d like you to do a swallow for me. No enlargement in the thyroid gland. Go to the front. I want you to do some movements for me. Please touch your chest with your chin. Can you look to the ceiling? Can you turn your head to the right? To the left. Any pain? 7

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Can you touch your shoulder with your ear on the right? How about on the left? Can you cough for me? Any pain? Then valsalva manoeuvre, can you press against my hand? Any pain?  Neck pain is not associated with any muscle spasm. Part of my exam is to look at your upper extremities. Please roll up your sleeves. Deltoid, biceps and triceps are normal and symmetrical. Forearm, thenar and hypothenar muscles of NL bulk. Check the tones in Stroke Pt. Start to move the hands. No cog wheeling at the wrist, elbow and there is no lead pipe rigidity. And there is no clasp knife spasticity (there is a click and then relax in stroke like Chaghoo-zaamendaar) (velocity dependent). (Tremor is on top of cog wheeling, but not with lead pipe) Can you touch your shoulders with your hands? (Support his arms with your hands). Do the sensory (peace of cotton and closure of both eyes) and exam the reflexes (biceps and brachioradialis: 5, 6- Triceps: 7, 8) then do the power (if you do biceps, triceps and deltoid it’s more than enough). I like to stretch your arm on the painful side, and then Turn your head to the opposite side, electric shock shows irritation of the nerve (It is equal to SLR in the legs). Check all the powers in hands, wrists, fingers and forearms and arms. Ask the patient to stand. Can you walk some steps for me? Check the gait. Say that you want to do the clonus. Then check the cranial nerves (just verbalize).

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UNCONSCIOUS PATIENT, STROKE, P/E: Knock, knock, knock, Do the introduction to Rule out the locked in syndrome also to confirm the unconsciousness of the patient. Hello, Mr. Douglas, Mr. Douglas, I am Dr. Miller one of the physicians working in the ER today. Can you open your eyes? Can you hear me?

The Pt. is not responding.

I want to open your eyes and shine the light in your eyes? Report the pupils now (dilated or constricted or round) If you hear me move your eyes up and down. Ask for Vitals: 1. Look for bradycardia and HTN or Cushing triad. 2. Look at the pattern of respiration and report it. 3. Feel the body and pay attention to the temperature. Check the GCS (3-15). In intubated Pt. 10+T  If no response then ask for intubation. Check the cranial nerves while unconscious: 1. CN2 with Ophthalmoscopy to see retinal haemorrhage, 2. CN3,4and 6 the eyes are deviated or not and the movement of the eyes and their symmetry. 3. CN2, 3 for papillary reaction, 4. CN5and7 corneal reflex. 5. CN9&10 gag reflex. 6. CN7 with facial expression also drooling and nasolabial folds. Then we go for upper extremity for inspection, check tone and reflexes, then the same for lower extremities report any spasticity or rigidity, dragging of leg is Nl. 9

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Then do the reflexes and Babinsky. Look at the examiner and ask if neck x-ray is clear Then I have to do meningeal signs: kerning in knee, brudzinsky in the neck and neck stiffness unless in trauma. Are there any brain stem reflexes. Then you have to mention oculocephalic tests and cephalocaloric test (just verbalize it). GCS: not in primary survey. In primary survey ABPU: alert... pain, unresponsiveness Verbal: talking normally: 5, short inappropriate sentences:4, inappropriate words:3, incomprehensible sounds:2, nothing:1. Motor: can you move your arm: 6. Press on sternum and localizing: 5, if withdraw: 4, flexion: 3or decorticate, extension: 2or decerebrate, none: 1.

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CRANIAL NERVE EXAMINATION: 12 pairs of cranial nerves: 1. CN1. (Kallman syndrome) : Just to be done in Quebec exams. Coffee and ammonia (Rule out malingering). 2. Start with the Optic nerve. It has 5 steps. In 2 of them you shine the light inside the eyes for fundoscopy and pupillary reaction. 3 of them the patient looks for visual fields, colour vision and visual acuity. 3. Then go for CN 3, 4 and 6 by extra ocular movements. (Pupillary reaction is 2&3.) 4. Then you go for 5thCN.The CN5 has sensory and motor components. For motor: clench your teeth and corneal reflex. 5. CN7 is mostly motor. 6. The CN8 is hearing, do Rhinne and Weber in Manitoba and Newfoundland exams. 7. The CNs 9th and 10th have 5 steps. 8. The CN11 has 2 steps (sternocleidomastoid and shrugging the shoulders). 9. Stick your tongue in CN12 exam. Knock, knock, knock (short introduction) Hello, good afternoon, Mr. Douglas, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here because of having head ache, and I have been asked to do the cranial nerve exam in the next 5 minutes. During my exam if you had any pain or discomfort, or any other concerns to stop, please do not hesitate to inform me. Taking the vitals  I am going to skip over the first cranial nerve.

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I am going to do the 2nd N. Exam: 1. Is it your best vision or you need eye glasses? Cover one eye with one hand and read the chart, middle line then jump down, and vice versa with the other eye do the same. 2. Ask about the colour both sides and in between. 3. Check the visual field. 4. I am going to shine the light into your eyes. Check for direct and indirect (consensual) reflexes (swing test). Afferent is 2, efferent is 3. Both pupils are round, symmetric and reactive to light, not dilated, not constricted. 5. I want to do fundoscopic exam. Why? I am looking for disc oedema and 2-3 signs of HTN (flame shape hemorrhage, AV nicking, exudates, cupper wire) and 2-3 signs of D.M. (hard exudates and neovascularisation). I am going to exam 3rd, 4th and 6th N.: (Corneal reflex is 5&7). 1. By Inspection both eyes are symmetrical, no deviation, no nystagmus, no head tilting, no ptosis. (Head tilting in cases of 4th N. palsy that the patient wants to put his gaze at the same level, so adjust their head to see straight, like Alexander who had syphilis neuropathy and head tilting)(Ptosis is for 3rd. N.). 2. Look at the tip of this pen and follow it with your eyes. At any time you had double vision, inform me, please. (H shape) Now we go the 5th N. (Trigeminal N.): Pay attention to temporal wasting, and clench your teeth (for masseter’s muscle). Check the sensory with piece of cotton with closed eyes in 3 sites vertically and bilaterally. Now we go to the 7th. N.: 1. By inspection face is symmetrical, Nl. Nasolabial folds, no drooling, and no deviation in the angle of mouth. 2. Now I’d like you to copy me and do some movements for me, can you raise your eyebrows, wrinkle your front or forehead, can you close your eyes and don’t let 12

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me open it. Can you puff out your cheeks, can you show me your teeth and smile, can you whistle 3. To the examiner: I’d like to do corneal reflex. CN8: Go to the back of the patient, Whisper house and horse and ask the patient to repeat them after you and do the wiggling fingers closing to ears, bilaterally. Now we go to 9 and 10. Give me a swallow, please. No hoarseness, NL voice, say AA, soft palate is symmetrical and uvula is central  To the examiner: I’d like to do gag reflex. Now the 11th N.: 1. Please shrug your shoulder while I press down, Nl.  Trapezius muscle. 2. I’d like to turn your head to the right side against my hand and to the left side the same  Nl. Sternocleidomastoid muscle. Now we reached the 12th N., Hypoglossal N.: 1. Would you please open your mouth, there is no fasciculation, there is no tongue atrophy. 2. Would you please stick out your tongue, tongue is central, no deviation, turn it to the right and left, normal movement. 3. Press your tongue against your cheeks. Tongue deviation is to the same side as the lesion. For face and uvula is opposite.

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Shoulder exam: Hello, Good afternoon, Mr. Walter, I am Dr. Miller one of the physicians working in this clinic today, as I understand you are here because you have pain in your shoulder for the last 2 weeks. I have been asked to do the physical exam. During my exam if you had any pain or discomfort, please do not hesitate to inform me. Also if you had any questions please do not hesitate to ask me. Also I will report my findings to the examiner, Is that OK with you? Can you give me the Vitals, please? V/S is stable; the patient is sitting comfortably with no signs of distress. I want to look at your shoulder; may I untie your gown? In my inspection, both shoulders are symmetrical; both clavicle and scapula bones are at the same level, Normal muscle bulk bilaterally, no signs of scars, erythema, atrophy, deformity or swelling. Normal cervical curvature. (Warm your hands)I want to feel your shoulder now. Temperature is Normal. I am going to press. Sternal notch is not tender, both sternoclavicular joints and both clavicles are not tender, acromioclavicular joints and acromions both are nontender. I am going to continue my exam on your left shoulder. Spine of Scapula is not tender also middle aspect and tip of scapula are not tender. When I am pressing on your spine in the neck do you have any pain? No sign of bursitis. I’d like you to relax. Move the shoulder up and down, no pain or tenderness in rotator cuff area. Glenohumeral joint is not tender. Check the sulcus sign to check Glenohumeral laxity. Check for cripitation in circular movement of the shoulder.

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Would you please put your gown back and stand up and face me, do you need my help? I’d like you to do some movements, can you move your arm forward, push back, (flexion and external rot.) (Extension and internal rotation) and can you cross your arms like this? Move to the side like this? Over your head and hold it? No drop arm (check external and internal rotation, abduction and adduction) can you touch your chest with your chin? Can you look to the ceiling? Can you turn your head to the right and left? Shoulder pain is not related to any neck lesion. There is no painful arch and there is no dropped arch, no signs of bicipital tendinitis, Normal power and sensation at the shoulders.

ROTATOR CUFF INJURY: Partial or complete tear, Impingement or Tendinitis. In complete tear, you cannot initiate movement and you have dropped arm. In partial tear he can initiate, but it is painful. So he puts his arm in supination to ease the movement and have further range. He will have dropped arm, but due to pain. Scarf test is done here. Apprehensions test (Handball players) or shoulder relocation test to show shoulder joint instability and anterior dislocation. Yergason’s test for bicipital tendinitis in flexion and supination.

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KNEE PAIN: QEII patient in this case is usually young. Hello, Good afternoon, Jack, I am Dr. Miller, one of the physicians working in this clinic today, as I understand you are here due to the knee pain for the last week. I have been asked to do the physical exam. During my exam at any time if you had any pain discomfort or questions, please do not hesitate to ask me, also I will report my findings to the examiner, is that OK with you? Can you tell me the Vitals, please?  By general Inspection, The patient is sitting comfortably with no signs of distress. Would you please stand up? Do you need my help? Can you put your gown a little bit up?  Both knees are symmetrical. NL joint alignment. No genu valgus or varus. Would you please walk to the wall? NL gait, no limping. No bulging in the popliteal fossa, no limping, NL gait. Turn and lie down. I am going to drape you; by inspection both quadriceps muscles have the same bulk, no scar, atrophy, oedema, erythema or swelling. Warm hands. I am going to feel your knee. Temperature is NL in both patellae and colder than the other parts of knee joint. If patellae and knee have the same temp, it means inflammation, doesn’t need to be warmer. Both knees are symmetrical with no local fever. Supra patellar pouch. Press and swing the patella to R/O chondromalacia. Then go to the large tendons and end up with tibial tuberosity(R/O Osgood-Schlatter). Lateral and medial collateral ligaments and press to the back.

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Bend your knee and feel up, down, middle. Feel lateral and medial tibial condyle. Check medial and lateral meniscus. Check crepitus and effusion. Patellar tapping and bulging sign or milking test. Range of movements: bend your knees, check flexion and extension. Check Power, push against my hand. Exam stability of knee. Anterior and posterior cruciate ligament by anterior posterior drawer tests the same test is Laschman’s test but in 15 degrees, medial and lateral collateral ligaments by varus and valgus stress test in 15 degree. Other knee exam and check the pulses. Tendon of quadriceps is attached to tibial tuberosity.

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HIP PAIN EXAM: Hello, Good afternoon, Mr. Douglas, I am Dr. Miller, I’m one of the physicians working in this clinic today, as I understand you are here due to the right hip pain for the last 3 days and I have been asked to do physical exam. During my exam at any time if you had any pain discomfort or questions or you wanted me to stop, please do not hesitate to ask me, also I will report my findings to the examiner, is that OK with you? Can you tell me the Vitals?

Temp.: 40 and the patient is febrile  The Pt. is sitting

comfortably and not in distress. Would you please stand up? Do you need help? If he cannot, exam him in lying down position with turning to the left side. I’d like to have full inspection, can I have full exposure? (If no: mention that hips and symphysis are deep seated joints and we cannot get a lot of information by inspection or palpation, however I am looking for any obvious swelling, erythema, tenderness or deformity. Lumbar curvature is NL. Gluteal folds are at the same level and both hips are symmetrical. I am going to feel the local temperature. I am going to press over the hips. Feel sacroiliac joint, posterior iliac spine, iliac crest and superior iliac spine. Would you please walk towards the wall? NL gait, no limping. Do Trendelenburg test? (To see the weakness of Gluteus Medius) Can you stretch your right leg towards the back, while you are holding the edge of the bed? I hold you from the back for support. Would you please lie down? Drape him. 18

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I’d like to have full inspection and feel the inguinal ligaments, head of the femur and greater Trochanter also Symphysis Pubis. Check the R.O.M. and bend your knee as much as you can. Then you do internal, external rotation, flexion and extension, adduction and abduction. 2 special tests: Patrick’s test and Thomas test. Up to 1 inch difference is accepted for the difference between the lengths of legs. Check the power. Press against my hands, up, down, in and out. Patrick’s (Faber’s) test: would you please bend your knee and put it above the other knee. I press on the knee to R/O sacroiliitis. If you bring the bent leg to touch the bed, it will check piriformis syndrome. (Please check these 2 tests on YouTube, too) The people with Osteoarthritis cannot have full extension. Hold one knee and stretch the other knee is Thomas test. If the stretching leg is elevated from the bed shows ileopsoas tightness.

Ankle exam: For ankle exam mention no open fracture, obvious swelling and bruises in trauma cases and SEADS in medical cases. In the case of pure physical exam, you can have long introduction. In cases of both history and physical exam, introduction would be shorter. Suppose that examiner is blind, so you have to verbalize as much as you can. They want to see how you react to stress or in difficult conditition. Really care about to find the Drape for the patient, even on the floor. First cover then put up the gown. Warm your hands (usually my hands are cold and I am going to warm them). Then warm your stethoscope with your coat. Always warn the patient before any movement. Can you show me where you have pain? Sympathize and do empathy. Tell him whatever you want to do on him, and ask him to do them.

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Cases: Cardiovascular cases: 1- 65 y/o with essential hypertension for the last 30 years, do P/E. 2- 35y/o with high blood pressure, do focused cardiovascular exam. 3-25y/y recently diagnosed with high blood pressure, do relevant P/E. 4-60y/o with cuff muscle pain, take history and do P/E. 5- Take history and do P/E for a patient with palpitation in 35y/o patient 6-Patient with cardiac Murmur 7- 70 y/o man having surgery 3 days ago, not passing urine for 4 hours, next 10 minutes do physical exam.( volume state exam) 8- Pt. had a surgery 3 days ago, now having shortness of breath for the last 2-3 hours, next 5 minutes do P/E. 9-Pt. had a car accident, or fracture or surgery 24 hours ago, now comes with S.O.B. (think of fat emboli or pulm. Emboli or athelectasis) do P/E for the next 5 minutes. 10-Pt. with S.O.B. for the last 3 hours after surgery 3 days ago in the next 10 minutes do focused P/E. 11-Pt. having history of Heart failure for the last 10 years. 3 days ago he has developed S.O.B. In the next 10 minutes do P/E? Respiratory cases: 1-Pt. has cough for the last 3 days. In the next 5 minutes do P/E? 2-55y/o Pt. has a history of breast cancer 5 years ago with mastectomy, received chemotherapy and radiation, now she is having cough or S.O.B. for the last 3 days, do a focused P/E. (primary fibrosis) 3-67y/o Pt. coughing blood, take history and do P/E in 10 minutes.

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GI system: A. Abdominal Pain: 1-24y/o female with lower abdominal pain for the last 24 hours, do P/E in 5 minutes. 2-35y/o woman came to the ER for severe abdominal pain for the last 2 hours, do P/E. 3-22y/o girl with the history of crohn’s disease for the last 5 years came with abdominal pain for the last 24 hours, do P/E in 5 minutes. 4- 30 y/o male with abdominal pain for the last 24 hours, do P/E in 5 minutes. B. GI bleeding: 1-61 y/o, well known alcoholic patient came to the ER with vomiting blood in next 5 minutes do P/E. (liver failure). 2-25 y/o Female Pt. with nasal bleeding, systematic and ENT exam. (Search for bruises and petechia) Neurological cases:

1-HIV patient with head ache since the last week, do cranial nerve exam in 5 minutes 2-Pt has difficulty in his vision, 40y/o, in next 10 minutes take history and do P/E 3-Pt with crooked face (Bell’s palsy) do relevant P/E. 4- In Newfoundland Pt. is coming with hearing loss. 5- Pt. with weakness in the right or left hand, look for power, tone and reflexes 6-Pt. with diabetic foot do neurovascular exam. (If 5 minutes: no Monofilament test, if 10 minutes they want it) 7- Unconscious patient, do neurological assessment 8-Pt. with back pain, do P/E MSK system: 1- Do all the joints, except elbow 2- Shoulder exam 3- neck exam 4- hand laceration and carpal tunnel syndrome 5-hip exam 6-knee trauma and c heck anterior and posterior cruciate ligament, medial and lateral collateral ligament and medial and lateral meniscus 21

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7- Osteoarthritis of the knee based on the age 8- Ankle sprain P/E or counselling, be careful to R/O fracture and ligament tear 9- Pt. who had acute back pain regardless of the age 10- 67y/o man with acute on chronic back pain for the last 6 months, 3 days ago started with severe back pain since 24 hours ago (Think of metastatic fractures, Prostatic malignancy or breast cancer or osteoporosis in old age) 11- Chronic back pain: If young think about Ankylosing spondylitis, if old think about spinal stenosis or osteoarthritis or facet joint Then we will go to the joints and related cases one by one which are all mentioned above.

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Mr Walter coming to clinic because of difficulty in swallowing for last 6 weeks, next 5 min take history (In 5 min cases you don’t need to give diagnosis) DDx: oesophageal cancer, scleroderma, strictures, web, rings and diffuse spasm. First see if it is intermittent or progressive. A) If intermittent  ask if it’s for solid/ fluid or both. 1. Solid and liquid  spasm. 2. Solid  ring or web. B) If progressive  ask if it’s for solid/ fluid or both. 1. Did it stuck both or fluid first? Achalasia or scleroderma, 2. Started with solid food, think of cancer (mechanical factor). Stroke/MS in brainstem affects coordination (whenever I eat foot, it comes out from my nose).

Approach: first clarify (what do you mean?), second analyse (where? Intermittent vs. Continues, solid vs. both) and then go to associated symptom, risk factors and R/O other possibilities (in young patient think of HIV), PMHx, FHx and finally Social Hx. KKK, Hello, good after noon Mr Douglas! I am doctor Miller, one physicians working in the clinic, nice to meet you. D: As I understand you are here because you have difficulty swallowing for last 6 wks, can you tell me more about it? P: Yes doctor for the last 6 wks I have difficulty swallowing, it’s not improving. When you say difficulty swallowing, what do you mean? P: Doctor whenever I eat, it is difficult! Food stuck. Can you show me where do you feel it stuck? Did it start suddenly or gradually? Gradually Do you remember what you did at that time? I was in a stake house......

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From that time till now, is it all the time or on-off? All the time Getting all the time. Solid or fluid? Solid food (meat) Were you able to flush it down? When you drink, did it help? Yes or no!!!! Is the first time or happened to you before? I am going to ask some questions to see if you have any symptoms related to that? Do you have any chest pain? Tightness? Do you vomit? Do you bring up undigested food? Any cough/ repeated chest infection/ change in your voice? Any abdominal pain/ distension/ change in bowel movement (constipation/diarrhea). Did you notice any blood in your stool or vomit blood?

Constitution symptom: fever, night sweat, weight loss, lumps and bumps. How much weight loss over how long? Any nausea vomiting, abdominal pain, tiredness (he is repeating)

Go for metastasis: do you have any yellow discoloration, itchiness, pale stool and dark urine? Any back pain? Risk factors: do you have any history of GERD? 1) If yes  when was that? How long was it? Did you seek medical attention? Did you ever have any studies done? Did they ever put any camera or light in to your chest? Did they ever tell you that you have a condition called Barrette esoghagitis? 2) If no  ask for the symptoms; heart burn, acidic taste in your mouth, use a lot of pillows for sleeping? Do you have history of smoke? Drink alcohol? Any family history of esophageal cancer? P: Yes my dad died of esophageal cancer. When and in which age? Any history of swallowing acid or alkaline? Chest surgery (not sure), chest radiation?

DDx: Any history of skin tightness? If you are exposed to cold or hot weather, do you feel that change in the color of your hand?

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PMHx: Hx of stroke, weakness, numbness, difficulty finding word, DM, any medication? +/- HIV?

Social Hx: How do you support yourself financially? How did it affect your life? How do you cope with it? (empathy should be put in appropriate places).

35 y/o male patient having fever for the last 6 weeks (history) *Think of HIV, Hepatitis, malignancies and spleenectomy. * Start with introduction then analyzing fever then go for constitutional symptoms and DDx (head to toe). Pay enough attention to liver; symptoms and risk factors. End up with PMHx, FHx and Social Hx. KKK, Hello Mr Hutson......... As I understand, you are here because you have fever for the last 6 wks, can you tell me more about it? Yes doc. ........... How did it start? Suddenly or gradually? At that time did you have any flu/illness? Did you seek any medical attention before? –NO  What motivated you to seek medical attention today? Maybe he say I started to have skin rash.... Increasing or decreasing? All the time or on-off? Did you measure it? How often do you measure it? How do you measure it? What was the highest measurement? Any variation or special pattern? Did you try and medication? Anything decrease/increase it? Is it the first time you have this or have had it before?

Constitutional symptoms..... I am going to ask you more questions to see if you have any other symptoms: Start with CNS; do you have any headache, nausea, vomiting, bothered by the light, neck pain, neck stiffness? Any pain in your ears, discharge in your ears? Runny nose? Any pain in your face? Sore throat? Difficulty swallowing? Any tooth problem? 3

4|Gastrointestinal

Any heart racing (IE)? Chest pain? SOB? Cough, phlegm, wheezing, chest tightness, contact with TB patients, have you ever been screened for TB (skin test)? Abdominal pain? Distension? Diarrhea? Change in bowel movement? Any flank pain, burning sensation, more go to the washroom, change in your urine? Any joint pain, joint swelling, Skin rash, ulcers in your body or mouth, red eye? Have you ever you or any of your family member been diagnosed by conditions called autoimmune disease? Like RA, SLE... Any history of liver disease, have you been screened for liver disease/HIV? Have you been vaccinated for hepatitis? Do you have any yellow discoloration, dark urine, pale stools, itchiness, increase in size of your abdomen(pants), any bruises and swelling in your legs? I am going to ask you some questions to see if you have exposed to liver disease without being aware of that, some of these questions might be personal but it is very important to ask them. I’d like you to know that whatever you tell me here is strictly confidential; I wouldn’t release any information without your permission unless I am requested by the law: 1. 2. 3. 4. 5.

Any travel outside Canada recently? Any raw fish/food, new restaurant? Any history of hospitalization/ surgery, receiving blood, donating blood (screen)? Any tattoo, piercing? Do you smoke, drink? Have you ever tried recreational drugs? If yes; ask about IV drugs/needle. 6. Sexual Hx: With whom do you live? Wife. How long have you been with your wife? 3 years. Before being with your wife did u have any sexual partner? Yes, from which age you become sexually active? 18 From that time till now how many partner have you had? 13 Did you practice safe sex always, I mean did you use condom in every single time? What is your sexual preference? Men, women or both? What type of sexual activity do you practice? Oral, anal or vaginal? Have you ever been diagnosed with any sexually transmitted disease?

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5|Gastrointestinal

Within the last 3 years have you had any other sexual partner in addition to your wife? Yes, when was the last time? Did you use protection? Do you have any discharge, any lumps in groin area, and any ulcers in genitalia? How about your wife, does she have any symptoms, fever, and discharge? Whenever you have fever, discharge, jaundice and lymph nodes, you need to ask good sexual history. How do support yourself financially? Have you ever been exposed to blood or bodily fluids at work?

PMHx: cancer, medications, allergies........ FHx: ...

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6|Gastrointestinal

Giving the Lab test result to the patient: 1-Introduce yourself 2- Why/where/who ordered it? 3- Explain the result 4- Consequences; symptoms of liver disease 5- Causes of liver disease 6- PMHx 7- FHx

Abnormal liver function test (ALT>AST): As I understand you are here to get the results of your blood work which was done 2 weeks age and I have the results and I am going to discuss it with you in a few minutes but because it’s first time I see you I am going to ask some Questions to help me get better understanding of these results. What’s the reason for doing this test? Insurance Is it the first time or have done it before? If yes.....when? And what was the result? Don’t need to go through the SPIKE, it is not that much bad to have elevated liver enzyme! Your results show that there is an elevation in one of the markers that use to assess function of your liver; we call it liver function test. If it’s elevated means there is an injury in the liver’s cells and they are different causes for that. Before talking about the causes I’d like to see if you have any symptoms related to that. Acute symptoms; any recent of yellow discoloration, itchiness, dark urine, pale stool, sever flu like symptoms with joint pain and muscle ache. Any change in your appetite, hate taste of cigarettes, N/V Chronic phase; did you notice any increase the size of your abdomen/belt, bruise, swelling in your ankles, vomiting blood and change in your memory. Have you ever been diagnosed/screened with/for liver disease before? Have you ever been vaccinated for HBV/HAV before?

6

7|Gastrointestinal

I am going to ask you some questions to see if you have exposed to lover disease without being aware of that, some of these questions might be personal but it is very important to ask them. Start with travel, any travel outside Canada recently, any raw fish/food, new restaurant, any history of hospitalization/ surgery, receiving blood, donating blood (screen), tattoo, piercing, do u smoke, drink, ever tried recreational drugs? If yes; ask about IV drugs/needle. This patient used to use heroin before. With whom do u live? how many partner have u had? How do support yourself financially? Have you ever been exposed to blood or bodily fluids at work? PMHx: blood disease, medication FHx: liver disease Thank you for the information, we need to do further assessment.

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8|Gastrointestinal

Problem with drinking (elevated liver enzymes or change in behaviour): First start with drinking habit then find impact in his life (medical, social, familial or psychiatric)

Abnormal liver function test (AST>ALT): I can see you are upset, can u explain to me why you are upset? P- Did you cancel my insurance? D- Definitely not, I am not aware of what insurance you are talking about, usually insurance companies determine whether to approve your application or not, from my prospective you are here to discuss your blood work which is related to liver. I am not sure if it’s related to your insurance company or not, most likely this the reason they cancelled your insurance. If the patient insists  I can see how much you are frustrated and understand how it is important for you. I can assure you again it is not me who determine that’s done in insurance company you can talk to them, however, since you are here there is something important to discuss and that’s your liver! The result of your blood work could be concerning to us. Is it the first time or have done it before? If yes.....when? And what was the result? Your results show that there is an elevation in one of the markers that use to assess function of your liver; we call it liver function test. If it’s elevated means there is an injury in the liver’s cells and they are different causes for that. Before talking about the causes I’d like to see if you have any symptoms related to that. P- Doctor! Why don’t you repeat my test? D- Mr..... whenever we do blood test and we find it abnormal we double check, if you would like to repeat that we can do that but usually it’s accurate. Not only that, based on history if you have any abnormalities in your liver we need to do further tests/assessments. Acute symptoms: any recent of yellow discoloration, itchiness, dark urine, pale stool, sever flu like symptoms with joint pain and muscle ache. Any change in your appetite, hate taste of cigarettes, nausea, vomiting? Chronic phase: Did you notice any increase the size of your abdomen/belt, bruise, swelling in your ankles, vomiting blood and change in your memory. 8

9|Gastrointestinal

Have you ever been diagnosed/screened with/for liver disease before? Have you ever been vaccinated for HBV/HAV before? I am going to ask you some questions to see if you have exposed to liver disease without being aware of that, some of these questions might be personal but it is very important to ask them: Start with travel outside Canada recently? raw fish/food? Any tattoo, piercing? Any history of hospitalization/ surgery, receiving blood, donating blood (screen)? Do you smoke, drink, have you ever tried recreational drugs? P- Yes I drink. How much do you drink? How long do you drink? P- Since I was 18. Last week how much did you drink? In a day? Have you ever drunk more than 6 drinks in one setting? What kind of alcohol do you like to drink? (10 beers in one day, 2 bottle of wine or 1 bottle of whisky in one day is considered a lot) Do “CAGE”: 1. 2. 3. 4.

Do u feel u need to cut down on your drinking habit? Have you been annoyed by the people criticise your drinking habit? Do you feel guilty because of your drinking habit? When you wake up in the morning do u feel that you need to take a drink to help you go through your day? (1 for women and 2 for men)

Ask about drinking habit: Do u drink alone or with friends? Do you exceed the amount of alcohol you plan to drink? Did you ever drink to the amount that you lost your consciousness? Do you avoid going to places where you don’t have access to alcohol? If you don’t drink, would you have shakiness, heart racing or excessive sweating? Impact: Because you have been drinking for a long time I’d like to ask some questions to see how it affects your life? With whom do you live? How is the relation? P- It’s not good, Why? For how long? Is there any stress? Do you think it is related to your drinking habit? You might ask about sexual function. How do you support yourself financially? How is your relation with your supervisor/coworkers? Do you need to miss a lot of days at work? Do you drink at work? Any legal consequences? Fight, criminal record, licence suspended....? How is your mood? Interest? Excessive fears? Do you hear voices or see things other people can’t? Any chance that you might harm yourself or somebody else? 9

10 | G a s t r o i n t e s t i n a l

Any Hx of psychiatric disease? Visited by psychiatrist? Any FH of drinking problem, suicide, depression? P- how about you doctor? Do u drink? D- Weather I drink or not, makes no difference, we are here to talk about you and it’s better to use this time to discuss your condition.

56 y/o male, hasn’t been himself for last 6 month KKK, Hello , good afternoon Mr. Talor, I am Dr. Miller one physician working in the clinic today. As I understand you are here because your wife is concerned about you and she asked you to come here to see me (arrange this meeting). Can you tell me more about her concern? Why she is upset? Why she is not happy? Or what’s bothering here? P: Oh she is nagging about everything, she says I am not staying at home (look for the change) and she says I waste my son time! D: You said you stay out more, when did it start? 6 month ago. Why, what happened 6 months ago? (any changes 6 month ago) P: Yes, I am a lawyer, I shifted to family law. D: Interesting, before working in family what kind of law did you practice? What made you change and how do you feel about family law? P: I am disappointed. How this affects you? Do you agree with your wife that there is change? She has a point? How do handle this/disappointment? Either we go for the mood or organic. We should ask about mood, drink and smoke in all the cases like this. Do you drink? Yes. How much do you drink? More than before. When did you start to drink more? 6 month ago. If he says; she is nagging about the fact that I am spending more time with our son. When he was young I didn’t have the chance to be with him, now he grew up and I want to compensate for that time! Why she doesn’t join you? Because of party! Then you ask about drink, smoke and drug. 10

11 | G a s t r o i n t e s t i n a l

A) Mr.... 24y/o with diarrhea for last 4 days B) Mr.... 28y/o with diarrhea for last 6 weeks

A) Hello, Mr. Davis, I am...... As I understand you came here because you have been having diarrhea for the last 4 days. Can you tell me more about it? Do yu remember how it started? Gradually. From that time until now is it all the time or on and off? P: All the time. Increasing or decreasing? Increasing. How many times in the first day? 3 times. How about today or yesterday? At least 7 or 8 times. How about during the night, do you wake up to go to the washroom or you are able to sleep? P: I have to wake up to go to washroom. That must be difficult, how did it affect your life? Is it the first time or happened before? Usually what is your habit? How often do you go to washroom? COCA+B: How about the color? Brown or green? How about the consistency? Is it watery, loos, well formed. Did you notice any blood? Any offensive smell? Is it bulky? Did you notice any undigested food? Any fatty droplet? Does it float on the toilet? Is it difficult to flush? Any mucous (it isn’t significant)? Anything increase it decrease it? Any medication? Which, did it help or not? Do you have any nausea and vomiting? No. Any recent flu? Did you eat in a place that you don’t eat regularly? Any raw chicken? Did anybody around you have similar complaint? Do you have any abdominal pain? If yes: OCD and ask which started before? Is your abdominal pain relieved when you have bowel movement or not? Do you have it during the night? After you pass your bowel movement do you think that you are done or you need to go again?

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12 | G a s t r o i n t e s t i n a l

Dehydration: ask about weightless? Do you feel dizzy/ light headedness/thirsty. If you stand do you feel you have heart racing? Causes: we covered the food poisoning and infection still we should ask about fever, night sweat, chills, appetite, bump and lumps. Have you used any antibiotics? P: Yes. When? Why? Which one? How long? Other DDx that you can touch them briefly; travel, camping, hyperthyroidism, lactase def, first attack of IBD. PMH, FHx........

B) DDx; cancer, infection, camping-parasite, hyperthyroidism, IBD, lactose intolerance, IBS, celiac, HIV, pancreatic failure..... KKK. Hello Mr Wolter..... As I understand you came here........ Whenever you feel you want to lie down, don’t hesitate to tell me. OCD..... Same as the previous one. During these 6 weeks did you have any time of constipation? Before this did you have any previous attacks of diarrhea? COCA+B...... about the blood; fresh, mixed, separate and dark stool. Go for pain: which started before? Continue with the same Questions for case A Constitution symptoms and add any family history of colon cancer at young age? Go for DDx; IBD: red eye, ulcer in the mouth, back pain, joint pain/swell, stiffness, uretritis, skin rash, nail changes and history of psoriasis.... Lactose intolerance: gases, distension, itchiness, a lot of dairy product than usual. Laxative, antibiotics. If you find HIV important ask about it.

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13 | G a s t r o i n t e s t i n a l

40 years old male, abdominal pain, 24 hours, take history (Obstruction): Female abdominal pain 1. 2. 3.

Missed period without bleeding= ectopic pregnancy Missed period with bleeding = abortion Discharge= PID

KKKKKKKKK Mr. Doglas, I’m Dr. miller, one of the physicans working in the ER today. As I understand you have been having severe abdominal pain for the last 24 hours, can you tell me more about your pain P: after breakfast I went to work, my pain star 2 hours later. - are you comfortable sitting? Do you like to lie down? Bear with me for a few minutes. As soon as I can I’ll give you pain killer. - how did it start? Suddenly or gradually From that time till now is it all the time or on and off? P: all the time, now - what about in the beginning? - when did it start to be all the time? P: last night ( empathy, asking sleep here or in severity, and any change in course is important. - is it the first time, or you have had it before? Can you show me where it is? How does it feel? P: dull -from the beginning? P: it was colicky at the beginning? -from score of 1 to 10, where do you put it you pain? Does it shoot anywhere? Were you able to sleep last night, anything increase it or decrease it? Medication, position, leaning forward? 13

14 | G a s t r o i n t e s t i n a l

(Always for abdominal pain ask nausea and vomiting) Do you have any nausea, vomiting P: Yes -COCA, amount, color, consistency, smell P: the smell was very awful - was it forceful, does it relieve your pain, which started first you pain or vomiting ? ( pain then vomiting =surgery. Vomiting then pain = medical (DKA)) - did you feel dizzy, light headedness, any dark urine( for dehydration)

P: I was out with my friends. - did you eat alone or with them? Anything new, do others have the same symptoms? Any change in your bowl movement? When was you last bowel movement? Usually how often do you have? Any distension? Are you still passing gas? Any blood with stool? ( consider the cause) 1. 2. 3. 4. 5.

Any history of surgical abdomen. FHx of bowl or colon cancer. Constitutional symptoms History of IBD, repeated attacks of pain with diarrhoea Any history of groin mass or surgery, have you ever been diagnosed with inguinal herniation, any history of gall bladder stone.

DDx: any flank pain, burning sensation, blood in urine, any skin discoloration, itchiness, and dark urine, any cough phlegm and wheezing, chest pain, Hypertension PMHx FHx Social Hx

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15 | G a s t r o i n t e s t i n a l

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1|Ph.Ex & Management

Counseling scenarios: Two sessions of smoking cessation, diabetes counseling (DM with impotence, DM with blurred vision), scenario of asking medical note from you which epileptic patients wants to get a notes for driving license, needle-stick scenarios, HIV scenarios, scenario for INR.

There are 32 pediatrics scenarios.

Obstetrics and gynecology: five subjects of history taking, and 10 subjects for counseling (OCP X 2 scenarios -- sexual abuse -- a lady comes for antenatal visit and she's panicking -- 2 scenarios for Pap smear; one wants Pap smear and the other one doesn't want Pap smear -- 2 C-sections; one wants to arrange a C-section and the other one doesn't want to C-section -- HRT scenario.

35 year old male come to clinic having chest pain. 10 minutes counseling. No checklist for this scenario.

Management: In the ER cases you should do ABCD plus history and physical examination. ER cases are divided to trauma and none trauma cases. Non-trauma cases are divided into cardiac and non-cardiac cases. The cardiac cases are divided to chest pain, heart block and arrhythmias. The arrhythmias are divided into stable or unstable.

The unstable arrhythmias like ventricular fibrillation or ventricular tachycardia which is a code blue situation you should perform ACLS protocol. You cannot wait to take history; you should shock the patient as soon as possible.

In trauma cases you should perform the ATLS protocol. In trauma cases the three situations:

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2|Ph.Ex & Management 1- Patient sustains a physical trauma and the scenarios are either a car accident, stabbed by knife, beaten by baseball bats or kicked by a horse. In the scenarios you should say I would like to initiate ATLS protocol. 2- Patient has sustained trauma and you should manage the patient over the phone. 3- Patient had primary survey done and you're asked to do secondary survey now.

There are four chest pain cases: 1- Patient arriving with evolving MI, so first ECG will be normal. So you should ask for serial ECGs. 2- Patient arrives and already he has got ST elevation. So in this case the patient is almost diagnosed. In this station is no cardiac enzymes and you should only look at ECGs. 3- Patient had chest pain and ventricular fibrillation and he's on the way to hospital. 4- Patient has chest pain and ventricular relation and you found he has taken cocaine (cocaine overdose). You should find the cocaine overdose by taking history.

There are two heart block scenarios: In both cases patient has got the pressure of 90/60 and heart rates is 45.

Non-cardiac cases:

A. GI cases: 1- Patient in ER with acute abdomen who has not know blood pressure and tachycardia. 2- 55 or 65-year-old patient vomited blood 20 minutes ago and his blood pressure is 90/60 and the heart rate is 110 (case of a upper GI bleeding). In 10 minutes manage the patient. 3- 69-year-old patient with rectal bleed having blood-pressure 90/60 and heart rate is either tachycardic or normal due to being on digoxin or B-blockers (lower GI bleeding).

There is no asthma case so far in the scenarios.

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3|Ph.Ex & Management

B. Neurology cases:

1-45-year-old patient who is seizing for the last time two minutes, paramedics gave him lorazepam on the way and brought him to hospital. 10 minutes management.

2-18-year-old patient came to emergency room because of severe sudden headache two hours ago. 10 minutes management.

3-16 year old patient who has been found unconscious in her class 5 minutes ago and her classmates brought her in emergency room. Next 10 minutes manage and counsel her.

4- 40 year old patient who is receiving blood and nurse is concerned about him and ask you to see the patient. This is all about side effects and complications of transfusion. In the next 10 minutes manage and counsel the patients.

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4|Ph.Ex & Management

ER Management 1- Trauma cases 2- Non-Trauma cases In any trauma scenarios, make sure you have proper IV lines and proper monitoring, so you can start primary survey. The purpose of Hx is not for diagnosis in emergency setting. The purpose of Hx is that the patient is alive and can talk to you. After a very brief Hx, tell the patient: I am going to make sure that you are stable, so I am going to give some orders to the nurse and as soon as it is done I am going to ask you some more questions. In the trauma cases you have to do extensive primary survey. After primary survey you have to do a quick Hx (AMPLE: Allergy, Medication, Past medical Hx, Last meal or last Tetanus and Event).

After a quick Hx (AMPLE) we should do a head to toe examination. At the end you should give some orders.

In Non-Trauma scenarios, we should do a quick primary survey, then HPI (History of Present Illness), OCD (Onset, Course, Duration), PQRST (Position, Quality, Radiation, Severity, Time/Triggers), AA (Alleviating & Aggregating factors), AS (Associated Symptoms), RF (Risk Factors), Past Medical Hx, then you should do a focused physical exam and then give some orders.

The common mistake is that to do an extensive primary survey for Non-trauma cases, or perform an extensive Hx on trauma cases.

Sample of Trauma case:

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5|Ph.Ex & Management

Case of MVA: Introduction: Walk towards the examiner and say: Hello. Because this is a case of trauma I would like to activate ATLS protocol and I will need protective measures including gown, gloves, goggles, and masks for myself and the rest of my team. Then walk toward the patient. While you are walking toward the patient, look if the patient is wearing neck collar or not.

If the neck collar is on, go and greet the nurse. Like: Dr Miller: Hello. Good afternoon, my name is Dr Miller.

If there is no neck collar on, ask the nurse to provide the collar and ask the patient to stay still and do not move his/her neck/head before you greet anybody. You may need to apply the neck collar.

Take a very small Hx:

Dr Miller: How do you feel right now? Patient may tell you he/she is in a lot of pain. So you are interested to know if he/she can talk or not? Patient may start with asking where my wife is.

Dr Miller: Mr Douglas, I know you are concern about your wife, but my priority is making sure you are stable. I will ask around about your wife and when I find out, I will update you. Patient may say I am in pain and I am dying in this hospital, please help me I am in a very severe pain.

Dr Miller: I can see you are in a lot of pain, bear with me for a few minute. I will you pain killer as soon as I can however at the moment I want to make sure you are stable, for that reason I am going to give some orders to the nurse.

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6|Ph.Ex & Management Start with A B C D:

1. “A” stands for Airway:

Ask the patient: Would you please open your mouth. When he opens his mouth you should verbalize your findings to the examiner like: Mouth is clear; there is no denture, no broken tooth, no foreign body, no blood and no clots. Patient is talking to me so the airway is clear. Then you should check the saturation first and see how much it is before starting O2 and compare it with after O2. If the saturation is not improving with O2, so either patient is not breathing well due to pain or something serious is going on.

2. Checking the saturation and oxygenation is the part of “B” (Breathing):

The new neck collars have a window in front, but the older ones do not. For the new neck collars you should open the window, but in old types If there is no window you should open the collar to observe the neck. In the neck you look for two things: 1- Trachea 2- Jugular veins Check the trachea to see if it is deviated or not, and jugular veins to see if they are engorged. You should verbalize your findings to the examiner.

Normal RIGHT Sided tension Pneumothorax

Trachea

Jugular Veins

Air entry

Heart Sounds

Central

Normal / 

Bilateral

S1/S2

Shifted to the LEFT

Right Sided

Shifted to the

Haemothorax

LEFT

Tamponade

Central

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

Normal /  

 in the RIGHT side  in the RIGHT side Bilateral

S1/S2

S1/S2 S1 / S2

7|Ph.Ex & Management Needle decompression for tension Pneumothorax will be located in the 2nd intercostal space at midclavicular line. In Tension Pneumothorax the gush of air will be heard.

The proper chest drain should be inserted on the upper boarder of the lower rib.

Once you put chest drain, you should ask the nurse how much blood is draining in the drain.

Call to thoracic surgeon if: -

Chest drain output is ≥ 1500 mL

-

Chest drain output is ≥ 800 mL in 4 hr (or output is ≥ 200 mL/hr)

If there is a tension Pneumothorax has developed on the LEFT side, you could safely insert a needle for decompression at the 2nd intercostal space in mid-clavicular line as it is as safe as the right side (Far from big vessels).

In the case of cardiac Tamponade (Muffled heart sounds + Low BP + Engorged JVPs), we should perform needle pericardiocentesis.

To perform a pericardiocentesis, use a long needle and syringe. The needle should be introduced just next to Xyphois process with 45 degree angled (aim to the left shoulder or the tip of scapula), and advance the needle while keep applying suction (-ve pressure) with the syringe.

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8|Ph.Ex & Management Always monitor the heart. If the needle hit the myocardium, it will induce arrhythmias. The drained blood is not clotted.

3. “C” stands for Circulation:

In circulation always start with vital signs. Once you get the vitals; as patient is tachycardic, tell the examiner that you would like to establish two IV lines (Gauge 16) in antecubital fossa. Through one line I would like to give 2L Ringer Lactate bolus (will give to everybody with trauma or GI bleeding, stable or not) as fast as possible. From the second line I would like to draw some bloods. The vitals needs to be checked every 10 min or when 2L Ringer Lactate is finished.

After first 2L of Ringer Lactate, there are 3 conditions: 1- Patient is stable, the 2L is gone and patient still is stable. In this case continue with maintenance. 2- After 2L of Ringer Lactate, the patient is not doing well or the BP is low or border line. In this situation give another 2L. 3- Patient’s BP is low + patient is not doing well and 2L is given but the BP is still low or BP drops more. In this situation give blood.

From the second line some blood should be drawn for following tests: CBC diff, Platelets, Electrolytes, fingerprint Glucose, INR, PTT, LFT, BUN, Cr, Toxicology, Alcohol level, Blood group and cross match ± Cardiac enzymes

Order 6 units of blood: 2 of them should be + O if the patient is male or – O if the patient is female (or it could be same group, not cross matched), and the remaining 4 units should be cross matched.

Cardiac monitoring is essential + checking the vitals every 5-10 minutes. Also ask for 12 lead ECG.

In case of having no IV access, the interosseous (drill the bone in adults) can be used. It can provide a good access to infuse fluid very fast.

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9|Ph.Ex & Management

If despite giving fluids or blood the BP is not improving, look for the source of bleeding. The skull has got not much space, blood collection in the neck should be visible and in the chest you could exam to find out about bleeding. But in the abdomen you cannot see the bleeding and you should look, listen and feel. If patient has guarding or severe tenderness or can see bruises, you should say: I would like to get surgical consultation, stat.

If the examiner tells you that the surgeon is not available, you should ask for FAST (Focused Abdominal Sonography for Trauma). If the fast is not available then you have to do DPL (Diagnostic Peritoneal Lavage).

After abdomen go to hips and press the pelvis. If patient has pain with this, you should say: I am suspicious to pelvis fracture and would like to wrap the sheet around the pelvis very tight and ask for orthopaedics consult stat.

Then you should check the lower extremities for shortening and external rotation (to rule out the neck of femur fracture).

****Out of audio clip comment**** Here, the speaker explains that for neck of femur fracture, we should apply “Thomas Splint”, but I think the Thomas splint is applicable for shaft of femur or shaft of tibia fracture.

If you applied a splint, you should check the pulses before and after application. 9|Page

10 | P h . E x & M a n a g e m e n t

In trauma cases you should perform “Log Rolling” in which you need 4-5 people to help you to role the patient on one side, so you could perform vertebral spinal process exam + DRE (Digital Rectal Examination) After Log Roll you can insert Folly catheter.

4. “D” can be D1, D2 or D3:

D1 stands for Deficits. The patient is either conscious or unconscious. If patient is conscious tell him, I would like to shine a light into your eYes. Now verbalize your findings: both pupils are round and reactive symmetrical, then ask the patient to squeeze my fingers (check the power of upper extremities). Now ask to wiggle his toes (motor of the lower extremities). Ask about sensation of your touch on the upper and lower extremities. Now explain to the examiner that the patient is neurologically intact. If the patient is unconscious shine the light for pupils’ reaction and use AVPU to determine the level of consciousness. D2 stands for Detoxification in case of poisoning. D3 stands for Drugs. In case of heart attack give the drugs here. At this stage give Thiamine, Glucose, Naloxan and Oxygen (Universal Antidote). Always give Thiamine before Glucose.

Then check the AMPLE (Allergy, Medications, Past medical history, Last meal or Last Tetanus or Last Period, Event). For event ask if the patient remember what happened? Does he remember everything before and after the accident? How did it happen? Head on collision or T-bone or rearended accident? Did you have head trauma? Did you lose your consciousness? Do you have any headache? Also check for nausea and vomiting.

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11 | P h . E x & M a n a g e m e n t

Important points in telephone conversations: -

The same as normal scenarios the introduction and asking the name of caller is necessary

-

Always ask about the caller’s telephone number and address

-

Tell the caller that you will call back if the line disconnected

-

Always start with a very short history

-

If there is an emergency so check the patient’s ABCDs and give instructions to the caller (In trauma cases the caller is a nurse)

Full checklist of trauma case by Dr Miller:

When you enter the rooms for trauma case after giving a sticker to examiner, always verbalize:

Because this is a trauma case, I would like to activate ATLS protocol.

I would like protective measures (Including Gown, Gloves, Goggles and mask) for myself and the rest of the team.

Walk toward the patient and introduce yourself and talk to him to assess the airway.

IN TRAUMA CASES THE AIM OF TALKING TO THE PATIENT IS TO IDENTIFY IF THE PATIENT IS AWAKE AND IF THE AIRWAY IS OPEN & CLEAR.

Dr Miller: Mr Douglas. Good afternoon. My name is Dr Miller, one of the physicians working in the emergency room.

Patient: Oh Dr. I am in a lot of pain.

Dr Miller: I can see that you are in pain, but bear with me for a few minutes and I will give you pain killer as soon as possible. I need to make sure you are stable, and I will give some orders to the nurse and also ask you some questions. 11 | P a g e

12 | P h . E x & M a n a g e m e n t

Dr Miller: Can you open your mouth? (Checking Airway) Verbalize: The patient’s mouth is clear; there is no foreign body, denture, clot or secretions.

Dr Miller to the nurse: Can you get the saturation? Nurse: Oxygen saturation is 95%. Dr Miller: Please give him oxygen 4 Lit/min via nasal prongs. After giving oxygen ask if it improved the saturation or not.

Now Dr should bend and get close to the patient’s face to check the patient’s Breathing by LOOK, FEEL and LISTEN.

LOOK for chest movement. FEEL for the patient’s expiration on your face. LISTEN to any breathing effort the patient is making.

Then the Dr needs to check the trachea and jugular veins by opening the neck collar’s window or by opening the neck collar to observe the area. Look for deviated trachea and engorged JVPs. Always verbalize your findings on trachea and jugular veins to the examiner.

Now you touch the chest wall - in front – for any open wound, bruises, deformity and then feel it for tenderness, pain or crepitation.

Then tell the patient that you are going to listen to the chest. Listen for any decreased air entry to the lungs.

If there are JVPs engorgements and deviated trachea along with the decreased air entry to one lung, so you are facing with tension Pneumothorax. You must decompress the tension by insertion of a large bore long needle in the second intercostal space at mid clavicular line in the side of pneumothorax.

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13 | P h . E x & M a n a g e m e n t You will hear the air escaping the chest via needle (Gush of air) and significant improve on patient’s feeling, saturation of oxygen, JVPs and shifted trachea. Listen again to the lungs.

Always be vigilant about pneumo-haemothorax, if there is no significant improvement.

After decompression, verbalize that you are going to put a proper chest drain in 5th intercostal space at mid or anterior axillary line.

When you checked the “B” for “Breathing”, start to check “C” for “Circulation” by asking about the Vital Signs. For any kind of trauma cases, you must order the followings: -

Two 16 gauge IV cannulas into ante-cubital fossa. (Obviously one for each side!)

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Set up IV infusion from one side. o 2 Lit Ringer Lactate / bolus / stat to be given as quick as possible

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Draw bloods from the other side for the followings: o CBC, diff, Platelets

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14 | P h . E x & M a n a g e m e n t o Electrolytes o Kidney function tests (BUN & Cr) o Liver function tests (Liver enzymes, PT, PTT, INR) o Blood grouping and cross match o Cardiac enzymes o Order 6 units of bloods: 

♂ : 2 Units of O positive + 4 Units of cross matched



♀ : 2 Units of O Negative + 4 Units of cross matched

o Alcohol level o Blood toxicology -

Order for 12 lead ECG

-

Finger prick Glucose level

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Portable chest X Ray

-

ECG monitoring + Pulse oxymetery monitoring

If the blood pressure is not improving despite giving 2 Lit of RL, you should check for the other sources of bleeding.

The skull has not got much space to collect too much blood. So look at the abdomen, pelvis and extremities for major sources of bleeding.

Observe the abdomen and verbalize your findings. Then listen followed by feel, tap and perform special tests to find any trauma to the intra-abdominal organs.

Large span and masses over liver and spleen area are suspicious for rupture. Superficial bruises, abnormal swelling, Cullen sign and Gray-Turner sign are all indications of possible internal bleedings.

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Cullen’s Sign:

Grey-Turner’s Sign:

If you are suspicious to any intra-abdominal bleeding you should ask for “Surgeon consultation, Stat”, and if the surgeons are not available, ask for FAST, and if there is no FAST available ask for DPL. Check the pelvis for stability by pushing down anterior superior iliac spine bilaterally. Any pain or laxity indicates fractured unstable pelvis. Ask for “Orthopaedics consultation, stat” after fixing the pelvis by wrapping and knotting the sheet or apply brace around patient’s hips. Using sheet and knots or applying special brace for temporary external pelvis fixation:

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16 | P h . E x & M a n a g e m e n t After pelvis, you should check the lower extremities. Shortening and external rotation of one leg indicates the Neck Of Femur Fracture (NOF#). Look for abnormal bruise, swelling and angulations of thigh and lower leg when you are suspicious of lower extremities long bone fractures. Always check the distal pulses, and if there is no pulse, you need apply traction.

“Thomas splint” can be used for shaft of femur or shaft of tibia fracture. Always check for pulses after applying any splint.

To finish the Circulation assessment, we should perform “Log Rolling”, which for we need at least 4 people to support 1- Head & Neck 2- Chest 3- Pelvis 4- Lower extremities while we roll the patient to the side. Look for any significant bruise, open wound, deformity, foreign body, and assess for spinal processes and paravertebral muscles tenderness. At the end need to perform anal area sensation followed a DRE to check the sphincter tone, blood in rectum and high-raised prostate.

If there are no abnormal findings, we can remove the hard board and ask for insertion of Foley catheter to measure intake and output especially for traumatic patients in hypovolemic shock.

To check the “D” for “Deficits”, start with checking the eYes and comment on pupils and their reaction to shining light. Ask the patient to squeeze your fingers as hard as he can to assess the upper extremities innervations and motor function and also ask to wiggle the toes to assess the lower extremities followed by checking superficial touch sensation over upper and lower extremities.

If all normal, verbalize that “the patient’s neurology is grossly intact”. To finish the primary survey, we need to check the AMPLE: - Allergy - Medications - Past medical history - Last meal / Last tetanus booster injection / Last period (♀) - Event (as the patient about the accident/event) 16 | P a g e

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Non-Trauma case management: Case of SEIZURE: A 40 years old male was brought to the ER by paramedics along with his wife because he had a seizure 20 minutes ago while they were having dinner in a restaurant. On the way to the ER, an injection of 10 mg Lorazepam is given to stop the seizure. You come to see the patient in ER and his wife is with him. Patient is not responding.

Knock. Knock. Knock. – Walk toward the wife.

Dr Miller: Hello, Good afternoon. My name is Dr Miller the physician in charge. Nice to meet you. Start to take a very short history from wife and respond to her concerns. Dr Miller: I can see how stressful the situation is for you, and I will do my best to save your husband. At the moment, I would like to make sure he is stable so I am going to talk to the nurse and give some orders, then I will ask some questions about what has happened. Inform her about what you are going to do. Then start to perform primary survey: ABCD → verbalize whatever you are doing during ABCD After checking the Airway & Breathing, give some orders for Circulation (ask for Vital Signs and put 2 large bore cannulas to give fluids and take all necessary blood works). The same as trauma case. Here as the patient is non-trauma, give only maintenance fluids (Normal Saline 50 mL/hr). Check the Deficits: D1: (patient is not responding so we can do AVPU and verbalize your findings) and then check for D2: Drugs/Medications: think of giving UNIVERSAL ANTIDOTES (Thiamine 100 mg, Glucose 50 mL of D50%W, Oxygen 4 Lit/min, Naloxan 0.4 - 1.0 mg). Always give Thiamine before Glucose. No need for Naloxan if the respiratory rate and oxygen saturation are normal.

The scenario may change by examiner to an immanent seizure attack if you forget to verbalize about universal antidotes. 17 | P a g e

18 | P h . E x & M a n a g e m e n t Now we have finished the primary survey and patient is stabilized so we should move to secondary survey by taking a long and detailed history. Ask the wife about the event (what she saw before, during and after seizure attack). Ask about the associated symptoms like fever, neck stiffness, vomiting for meningitis/encephalitis, constitutional symptoms for brain tumors. The focal neurologic symptoms before the seizure could be a clue so needs to be asked.

It is important to ask about husbands’ past medical history, previous hospital admissions and his medications: History of heart racing, history of clot in the leg/lung which for patient may take blood thinner (warfarin) or any history of head trauma which all is important clues as it could be the cause of intracranial bleeding. We should ask about patient’s regular medicines & social history: Sleeping tablets (withdrawal)? Smoking? Alcohol? Drugs?

After the detailed Hx, ask about the vital signs and start to perform the secondary survey (head to toe examination). Start with neurologic examinations: GCS, Cranial Nerves, Upper & Lower extremities, Special test for meningeal irritation (Neck stiffness, Kernig’s & Brudzinski's). Verbalize what you willing to arrange according to your neurological findings (Septic work up, LP, CT, MRI, ICU admission, Neurologist consultation etc.)

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Case of Headache: Diabetic teenager came to ER because he has severe headache for the last 2 hours and started while he was playing basketball. In these types of scenarios, there are buzz words like: “The worst headache in my life” or “Thunderclap”, which give you a clue about intracranial haemorrhage.

Start by taking history of the headache: OCD & PQRST & AS & AA & RF Offer the patient to lie down, if he refuses because of increasing pain (more clues about intracranial event), offer a 45 degree position to give him some comfort position.

Check the vital signs and look for Cushing’s Triad. Check the BM as soon as possible because the patient is diabetics. (Ask to check the BM regularly)

Usually in this scenario patient will lose consciousness while talking to you, so when happened we should start with primary survey and ABCD.

On “D” or “Deficits”, we should perform more detailed neurologic examination, also give universal antidote (Thiamine & Glucose & Oxygen) as patient is diabetic.

In neurologic assessment we have to do GCS, and for sure the patient’s GCS is 3cm above sternal angle is pathologic (raised ventricular filling pressure or volume overload often from RHF). ****** Key is 3cm and JVP has 3 letters ****** Then you need to examine the heart; → Verbalize your exam & findings Inspect Check and feel the PMI (not enlargement, not displacement, not diffused, not sustained) Check and for the apex and para-sternal heaves Check and for the thrills

Listen to the heart for any murmur, click and comment on the normal S1 & S2 Ask the patient to roll on his left side and check (with bell side of your stethoscope) for S3 & S4 Now examine the abdomen; → Verbalize your exam & findings Inspect for distension, palpating mass Look for café-au-lait spots or striae Listen for bruits of Aorta (2” above umbilicus), renal arteries (left and right of umbilicus) and iliac arteries (in a 45 degree - half way from umbilicus towards the anterior superior iliac spine) Tap the abdomen for any pain or dullness over renal and supra-renal areas Feel deeper for any pulsating mass

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26 | P h . E x & M a n a g e m e n t Then check the lower extremities; → Verbalize your exam & findings Check the femoral pulses (only verbalize that you want to do it) Check for Radio-Femoral delay Check for peripheral edema, Nail atrophy, and capillary refill Check for Ankle Brachial Pressure Index (ABPI)

Ask the patient to sit up and now listen to the base of the lungs for crepitation, between the scapulae for any bruit (collateral circulation due to coarctation of aorta) and feel and press over the sacrum for any edema.

Perform the ankle reflexes (increased in hyperthyroidism, and delayed relaxation in hypothyroidism)

CURRENT Medical Diagnosis & Treatment 2010: Malignant hypertension is by historical definition characterized by encephalopathy or nephropathy with accompanying papilledema. Progressive kidney disease usually ensues if treatment is not provided. The therapeutic approach is identical to that used with other antihypertensive emergencies. Parenteral therapy is indicated in most hypertensive emergencies, especially if encephalopathy is present. The initial goal in hypertensive emergencies is to reduce the pressure by no more than 25% (within minutes to 1 or 2 hours) and then toward a level of 160/100 mm Hg within 2–6 hours. Excessive reductions in pressure may precipitate coronary, cerebral, or renal ischemia. To avoid such declines, the use of agents that have a predictable, dose-dependent, transient and not precipitous antihypertensive effect is preferable. In that regard, the use of sublingual or oral fastacting nifedipine preparations is best avoided.

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CURRENT Medical Diagnosis & Treatment 2010: Identifiable causes of hypertension. Sleep apnea Drug-induced or drug-related Chronic kidney disease Primary aldosteronism Renovascular disease Long-term corticosteroid therapy and Cushing syndrome Pheochromocytoma Coarctation of the aorta Thyroid or parathyroid disease

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Case of Volume status assessment: A 79 years old male had a total hip replacement 3 days ago. The nurse has concerns as he did not pass urine for the last 4 hours. The folly catheter has been removed this morning.

The best indices of hydration in post op patients are: Orthostatic hypotension and Urine output.

Knock. Knock. Knock.

Dr Miller: Hello. Good afternoon. My name is Dr Miller one of physicians working in the surgical department today. My understanding is that you had a hip replacement 3 days ago, and the nurse is worried about you as you have not passed urine in the last 4 hours. I am going to perform physical examination. Do you have any question before I proceed?

Ask for the vital signs. You may need to demonstrate how to measure the vital signs specially BP. Explain the patient that you are going to check his blood pressure and heart rate while lying down and once again when you ask him to sit up after 2 minutes.

Make sure you choose the right cuff for BP measurement by one of 2 following rules: 1- The width of cuff should be 40% of patient’s arm circumference. 2- The width of cuff should cover 2/3 of patient’s length of the arm.

First check the systolic BP by palpation, then check the BP by auscultation (inflate only 30 mmHg above systolic BP by pulse). There is a difference between two readings, which is called “auscultatory gap”.

Now ask the patient to sit up and wait for 2 minutes to measure orthostatic pressure. During the 2 minute you can continue with other examinations.

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Start with checking patient’s orientation to place, time and person; Do you know where you are now? (Orientation to place) Do you know what date it is? (Orientation to time) Do you know why you are here? (Orientation to person) Then comment about patient’s orientation to the examiner.

While the patient is sit up, listen to the lungs and check the sacrum edema.

You can examine the eYes and comment about pallor or jaundice. Also look inside patient’s mouth for hydration status and cyanosis by asking to flip up the tongue.

Then you can check the hand and comment if the skin is dry or moist, temperature, and capillary refill.

Now the 2 minutes are passed, so you can re-check the HR & BP while sitting. If the HR increased by 20 beats per minutes, or systolic BP dropped by 20 mmHg, or diastolic BP dropped by 10 mmHg (or dropped 15 mmHg in average) will be significant of orthostatic hypotension.

Then tilt the bed to 45 degree and observe and measure the JVP. Verbalize your findings…. The same as above.

After JVP, examine the chest/heart, abdomen and lower extremities. In the abdomen you have to tap over bladder area to assess if the bladder is full or not. Finish the physical exam by explaining the examiner that you would like to see input / output and weight chart and also you will do a fluid challenge. You may consider putting a Foley catheter.

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Case of Blood Transfusion Reaction (unintentional medical error): You are called to see a patient who was receiving blood and he has developed temperature and the BP has dropped. Nurse has found that the patient has received the wrong blood, so she has stopped the transfusion and called the doctor. She insists you not to tell the patient about mistake she has made. Do management in next 10 minutes.

Dr Miller: Hello. Did you called me to see your patient? As I understand he showed some reaction to transfused blood. Nurse: He received a wrong blood transfusion. I am worried about him as he runs a temperature and his blood pressure is low. Patient is angry about what has happened. Dr Miller: have you stopped the blood transfusion? Nurse: Yes I did. I removed the cannula and left the remaining blood and bag to send back to the blood bank. Nurse: please do not tell the patient that it was my mistake. He is going to complaint and I will loose my job. Dr Miller: Errors happen. It’s important to make sure that patient is safe. Now, let’s go to see the patient first and we will discuss about it later when we made sure the patient is safe. Ethics: When there is an unintentional medical error, we have to tell the patient and fill an incident form. Patient has all the right to know.

Now Dr Miller is talking to the patient: Dr Miller: Hello Mr Douglas. My name is Dr Miller, one of the physicians working in this hospital. Patient: What nurse was telling you? What has happened? Dr Miller: She was explaining about the incident has happened and also about her concerns. As you know Mr Douglas, unintentional medical errors happens. My priority is to make sure you are stable and safe. Patient: Who is responsible for that? Dr Miller: We do not know as yet. We need to investigate and I am going to fill an incidence form. As soon as we have got any result from our investigation, we will let you know. Dr Miller: I should perform physical examination and make sure you are stable. 30 | P a g e

31 | P h . E x & M a n a g e m e n t

Start your examination with ABCD

Blood transfusion has three different reactions. One of them is anaphylaxis, so make sure there is no swelling inside the mouth and airway is clear. Can you hear any wheeze?

Check A: Ask the patient how is your breathing? Do you feel any itching inside your throat?

Check B: Listen to the lungs for checking air entry, and heart sounds. Check the oxygen saturation and give oxygen regardless.

Check C: Ask about vital signs. Then ask for removing the previous IV line and insert a new IV line and give fluid. How much? Depend what are the vitals?

Make sure patient has at least one IV access before removing blood transfusion cannula (Be worried about immanent shock, so do not leave the patient without IV access)

The previous IV cannula along with all tubes and remaining blood should be sent back to blood bank for analysis and re-crossed.

Inform the blood bank about the error, to make sure that patient’s matched blood is not been sent to another patient by mistake.

Draw a complete set of blood samples for routine bloods and coombs’ test, FDP (Fibrinogen Degradation Products), and Haptoglobuline. Check the bilirubin and liver enzymes along with coagulation profile. Send a urine sample as well.

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Check D: Check the pupils and verbalize your findings when you shine the light. Check for the power and sensation of upper and lower extremities. Verbalize: Patient is grossly neurologically intact. Give Tylenol for his temperature.

Ask the nurse to prepare and keep Epinephrine, Steroid, Diphenhydramine and Fluids close to the patient.

Now the primary survey is over and you should move to secondary survey, by taking history.

History: Febrile reaction questions: Do you feel any temperature or chills? Did you have any temperature or chills before receiving blood?

Anaphylactic reaction questions: Do you feel any itching inside your mouth? Do you feel itching on the skin? Have you developed any hives? Do you feel any wheeze or SOB?

Hemolytic reaction questions: Do you have any back pain? Press on his back and make sure if he feels any pain. Do you have any flank pain? Press on his flanks and make sure if he feels any pain. Check the site of IV line and verbalize: There is no oozing at the site of IV line.

Is it the first time you received blood? If no, why you received blood before? Why you are receiving blood today? Do you have any long term disease?

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Now start counseling: Mr Douglas, blood transfusion is a life saving measure. It’s common to receive blood and thousands of people receive blood every year. We take a lot of measures to make sure it is safe. However like any other medical intervention, there are some side effects related to transfusion, which could be serious. The most common side effect is fever or febrile reaction, which is around 3%, usually self limited and it might happen again. We are going to give you Tylenol next time to prevent febrile reaction. The other one is called anaphylactic reaction that is kind of severe hypersensivity or allergy. It is very serious but we cannot predict it and it might happen any time. However we have good treatment for it and we know how to deal with it and the symptoms you showed are less likely to be any anaphylactic reaction. The third reaction is more serious and it is called hemolytic reaction. It happens when patient receiving blood from other blood groups. Bear in mind the blood you received is from the same blood group; however we sent the remaining to the blood bank for analysis and re-cross match. I will update you as soon as I receive any news from blood bank. For the time being, my priority is to make sure you are stable, so we continue monitoring. Two important points you have to verbalize are: •

I am going to fill an incident form

•

I am going to inform the blood bank about the error and prevent sending patient’s blood to someone else by mistake.

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Case of Acute Abdomen: 42 years old male has come to the ER because of abdominal pain for the last 24 hours.

Knock. Knock. Knock. Dr Miller: Hello Mr Douglas. My name is Dr Miller one of the doctors working in the ER today. Please to meet you. As far as I understand, you have acute abdominal pain for the last 24 hours. For the next 10 minutes I am going to perform abdominal examination and report my observations and findings to the examiner. During my exam, if you had any pain or discomfort please let me know.

Look at the examiner and ask for the vital signs. Verbalize your finding about general appearance; By looking at the patient he is comfortable lying down without any distress.

Check the eyes for pallor or jaundice. Check the mouth for any sign of dehydration. Then check the hands for capillary refill.

Now you should cover the patient with a sheet (DO NOT EXPOSE BEFORE YOU DRAPE) and always explain to the patient what you are going to do. (Always frame the situation and your actions to the patient) Dr Miller: I am going to drape you with this sheet and then expose your abdomen for examination. Is that OK with you? Dr Miller: could you please roll up your gown? Do you mind if I roll your gown up?

Observe the abdomen and verbalize to the examiner your findings along with your observations; By looking at the abdomen, the abdomen is flat, not distended, abdomen moves with breathing, the umbilicus is inverted and there are no scars or bruises.

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35 | P h . E x & M a n a g e m e n t Ask the patient to turn his head to the left and make a cough to check if there is any cough tenderness. You should observe the patient’s face. If there is no discomfort, ask for the second cough and now look at the abdomen for any abnormal bulging or herniation.

Then warm your stethoscope and listen to the bowel sounds at McBurney’s point. Always explain to patient what you are going to do, check the stethoscope temperature on patient’s arm and verbalize your findings for examiner. Also check for Aortic, Renal and Iliac bruits.

Now tap the abdomen (in 9 points). Check for tenderness.

Then perform superficial palpation in all 9 areas. Always frame for the patient, what you are doing and verbalize to the examiner about your findings. Now do deeper palpation and look for any palpable masses, and check for kidney sizes.

Perform special tests: Murphy sign (press down at the area of gall bladder while patient takes deep breath) McBurney’s tenderness or rebound tenderness Rovsing sign (pressing over left lower quadrant causes pain in RLQ) Psoas sign (only on the right side) Obturator sign CVA tenderness

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Then sit up the patient and check the breath sounds at the bases of lungs, and check for sacral edema.

At the end verbalize you are going to feel inguinal areas for hernias, will perform digital rectal exam for blood, hemorrhoids, and assess the prostate, if patient is woman will do bimanual pelvic exam to look for any discharge, bleeding, adnexal mass or cervical tenderness.

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Case of acute abdomen (Crohn’s disease): Male patient with a history of Crohn’s disease for the last 5 years has come to ER with abdominal pain for the last 24 hours.

Knock. Knock. Knock. Dr Miller: Hello. Good afternoon. My name is Dr Miller one of the physicians in the ER. As far as I understand you have abdominal pain for the last 24 hours. Also you have Crohn’s disease for the last 5 years. For the next 10 minutes I am going to perform abdominal examination and report my observations and findings to the examiner. During my exam, if you had any pain or discomfort please let me know. Look at the examiner and ask for the vital signs. Verbalize your finding about general appearance; By looking at the patient he is comfortable lying down without any distress. No signs of truncal obesity because of use of steroids.

Check the eYes for redness, pallor or jaundice. Check the mouth for any sign of dehydration or mouth ulcers. Check the face for moon face due to long term steroid use. Then check the hands for nail changes, clubbing, skin rash or psoriatic changes. Check for capillary refill.

Observe the abdomen and verbalize to the examiner your findings along with your observations; By looking at the abdomen, the abdomen is flat, not distended, abdomen moves with breathing, the umbilicus is inverted and there are no scars or bruises. Check for Striae. Ask the patient to turn his head to the left and make a cough to check if there is any cough tenderness. You should observe the patient’s face. If there is no discomfort, ask for the second cough and now look at the abdomen for any abnormal bulging or herniation.

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Then warm your stethoscope and listen to the bowel sounds at McBurney’s point. Also check for Aortic, Renal and Iliac bruits. Verbalize your findings to examiner.

Warm your hands before touching patients abdomen. Perform superficial palpation in all 9 areas. Check the span of liver by tapping from the top and deep palpation from the bottom. Check the spleen span by deep palpation from RLQ towards the LUQ. Now do deep palpation all around and look for any palpable masses, or abscess.

Perform special tests: Murphy sign McBurney’s tenderness or rebound tenderness Rovsing sign Psoas sign Obturator sign CVA tenderness

Check the lower extremities for joint swelling and Erythema Nodosum.

Then sit up the patient and check the breath sounds at the bases of lungs, and check for sacroiliac joint tenderness.

At the end verbalize you are going to feel inguinal areas for hernias, will perform digital rectal exam for blood, hemorrhoids, and fissures. If patient is woman you should perform bimanual pelvic exam to look for any discharge, bleeding, and adnexal mass or cervical tenderness.

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Case of Shortness of Breath following a surgery done 3 days ago:

Male patient who had operation 3 days ago has developed shortness of breath for the last 20 minutes. You are called to assess the patient. Do physical examination

Knock. Knock. Knock.

Dr Miller: Hello. Mr Green. My name is Dr Miller one of the physicians in the ER. As far as I understand you had an operation 3 days ago and now you have developed shortness of breath for the last 20 minutes. For the next 10 minutes I am going to perform physical examination and report my observations and findings to the examiner. Do you have any question? Look at the examiner and ask for the vital signs and ask for orthostatic hypotension.

The examination starts with checking patient’s orientation to place, time and person; Do you know where you are now? (Orientation to place) Do you know what date it is? (Orientation to time) Do you know why you are here? (Orientation to person) Then comment about patient’s orientation to the examiner.

Verbalize your finding about general appearance; By looking at the patient he is lying down with no pain but some shortness of breath.

Check the eYes for pallor or jaundice.

Check for any nasal flaring.

Check the mouth for any sign of dehydration, central cyanosis, and pursed lips.

Verbalize about any sign of respiratory distress according to your observations.

Then check the hands for peripheral cyanosis, clubbing. 39 | P a g e

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Check for capillary refill and skin to see if it is dry or moist.

Check the pulse and comment on the character of pulses; pulses are symmetrical, sinus, normal in volume, and contour. There is no delay on pulses.

Look at the lower extremities for any swelling or erythema compatible with DVT.

Check the lower legs and feet for skin temperature, pulses of dorsalis pedis and tibialis posterior.

Check for capillary refill and peripheral edema.

Squeeze the calves and look for tenderness related to DVT.

You should compare the calves’ circumferences diameters by measuring around calves exactly 10 cm below the tibial tuberosities (land mark)

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If the difference of circumferences are >2.5 cm, it is significant for DVT.

DVT specific test: Homan’s sign: This test is controversial, just verbalize it.

Now you should examine the respiratory system by starting to observe and examine the neck.

Check the neck by looking at trachea and make sure it is central. Check if any accessory muscle is used for breathing. Look and feel for any lymphadenopathy.

Check the JVP at 45 degrees, and verbalize your findings to the examiner. 41 | P a g e

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Then examine the chest starting by inspection of the chest; By inspection there are symmetrical movements of the chest, no intercostal retraction, no accessory muscle is used for breathing.

PMI is obvious. Comment about PMI if you have time. Check for heaves and thrills. Feel the chest for any local tenderness. Check the vocal fremitus by asking the patient to say 99 while you are feeling the chest by palms.

Ask the patient to take deep breath in and out while your palms are on the chest wall and measuring chest expansion. From the back check the level of diaphragm by tapping the chest wall, then ask the patient to take a deep breath and tap again. If the movement of diaphragm is >5 cm so it considered as normal.

Listen to the heart sounds (S1 & S2). Turn to bell side of stethoscope to listen for S3 or S4. Listen to the aortic, pulmonary, mitral and tricuspid valve areas for any murmur, splitting of S2 over pulmonary valve (in Pulmonary Embolism S2 splitting is prolonged).

Now listen to the breath sounds by comparing each point with same point on the other side of chest. Listen over 6 points of chest anteriorly. Listen to the mid axillary line for middle lobes. Listen to the back and base of the lungs for inferior lobes. + feel for sacral edema.

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The sequence of this examination is different with the other examinations. Why? Because in this scenario you must examine the lower leg examination, so the lung and heart examination should be performed at the end if you have time.

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1|Neurology

Headache, temporal arteritis 67 male with headache, 10 days, emergency room, 5 min Hx KKKKKKKK Dr: hello Mr. Douglas I’m Dr. Miller one of the physician working in the emergency room. (or I’m the doctor in charge in the emergency room) as I understand you are here because you have been having severe headache for the last ten days, could you tell me more about it from the moment it started? P: increasing headache and Not improving Dr: How did it start? P: gradually Dr: from that time till Now, is it on and off or is it all the time? P: it is all the time (So every primary headache is Not related or concerning for long period) Dr: is it increasing, decreasing or the same? Dr: would you say it is the worst headache in your life? P: Yes (But it is Not SAH because 10 days) Dr: did you Notice any variation? Is it more at certain time of the day? And does it wake you up from sleep? P: No Empathy because it is continuous: were you able to sleep last night? P: No, for 3 days Dr: How are you coping, it must be difficult. You’ve done the right thing by coming here. Hopefully we’ll be able to deal with it. Dr: can you show me where your headache is? .....Is it always here?..... How does it feel? P: it is vague,

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2|Neurology

Dr: is it throbbing? P: No, it is deep and dull Dr: does it shoot anywhere? P: No Dr: on scale from 1 to 10, in which 10 is the worst pain, where do you put it? (Because it is one episode trigger is Not relevant) Dr: anything increase or decrease it? Is it related to coughing? Leaning forward, lifting objects, lying down? Dr: did you try any medication? How much did you take? Did it help? Transition for associated sx: in addition to your headache did you Notice any other symptoms? Constitutional: Dr: do you have any fever, night sweats, chills, lumps and bumps, loss of appetite, weight loss? P: No Infection: Dr: any vomiting, nausea, any neck pain, any bothered by light, any recent flulike symptom, ear infection, skin rash? Anybody around you have headache? Localization, neurological screening: Dr: Do you have any change in your vision, hearing problem, buzzing sound, difficulty swallowing, difficulty finding words, did you have any weakness, numbness in your arm and legs, any difficulty with your balance, any falls, any change in your bowl movement, difficulty passing urine, any dizziness, light-headedness, jerking movement, loss of consciousness, any history of seizure, any mood changes, concentration, memory problem, anybody told you that there’s change in your personality? P: I have difficulty with my vision. Dr: what kind of change? P: curtain falling or blurry vision (in TA) Dr: one eye or both, when did it start? (Because we have eNough evidence to suspect temporal artritis we should either roll out or confirm it.) 2

3|Neurology

Dr: when you touch this part, does it fell painful? When you combing your hair is it painful? Do you feel any cord-like structure? When you are chewing do you have any cramps? Do you have any pain or weakness in your shoulders and hips? (go back to neurological screening after vision) Any history of head injury or fall? Any blood thinner? Do you drink alcohol? ( for subdural hematoma) (Depressing in elderly is ddx, and we r/o by asking mood) Extra cranial causes: Any pain in your eyes, any redness, do you need eye glasses, do you have history of sinusitis? Any pain in your face, runny Nose, ear pain, pain with your teeth? History of hypertension, Rebound headache Do you take any medication or pain killer? How much? PMHx FHx Social Hx

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4|Neurology

Case 24 female headache in the last six weeks

KKK D: introduction, open ended question P: for the last six weeks severe headache Not improving D: I’m glad you come here today. Do you have headache at this moment? How did it start? From that time till Now, is it continuous or on and off? How often (how many times)? (Frequency at the beginning and Now) D: How long does it take each time? Can you show me where is your headache? P: always right. D: How does it feel like? Throbbing, dull? Does it shoot anywhere? P: No D: on scale from 1 to 10 where do you put it your pain Now and before? Is there any variation? Do you wake up with headache? Any relation between your headache and cheese, chocolate, coffee and red wine? Lack of sleep, stress, flashing lights, certain smells? Is it related to your period? Do you take any medication? What about birth control pill? What kind? How long? Have you changed it recently? Anything increase it? Anything decrease it? Is it increased by load Noise/ light? Do you try to go to quiet room and try to relax? Does Any medication help? Is it the first time or you’ve had headache before? Which kind? When? Any treatment? P: it was usually one day.

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5|Neurology

Constitutional Sx Local Sx DDx: Any stress in your life? Financial concerns? With whom do you live? PMHx, FHx, social Hx Drug and alcohol Counseling: Most likely your headache is related to migraine you are having, but because you’ve started new tablet, sometimes in some patients it might increase or trigger the event of migraine. What I recommend is you discontinue it and go back to your family doctor to change it and five you aNother form of contraceptive, progesterone or IUD.

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6|Neurology

35 male headache 4 weeks, hx

KKK 1. The patient gives us the clue Introduction P: for the last four weeks I have severe headache without improving and I’m concern D: what kind of concern do you have? P: I’m afraid I’ll lose my job? D: what makes you feel that? P: because I have headache at work. 2. Patient doesn’t give any clue D: How did it start? P: gradually D: from that time till Now is it on and off or all the time? P: all the time D: is it increasing, decreasing or the same P: increasing D: did you seek medical attention before? P: No Anything increases it, decrease it, leaning forward, wake up D: How often do you have attack? P: almost every day How long does it last? In the evening: P: after my work? D: what do you do for the living? Any certain setting? What about on the weekends? 6

7|Neurology

P: headache free. Associated Sx: What do you do for the living? P: Fork-lifter Is it open or close environment? Do you have any measurement alarm for co poisoning? How often this place get checked and anybody else has the same headache at work? PMHx FHx Social Hx (How to finish 5 min scenario: I’ll do PhEx do some blood work and imaging and we will take it from there.)

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24 male has headache for the last six weeks, history and counseling Approach to headache: 1. Intermittent: primary: tension, migraine, cluster 2. Constant: secondary

KKKK Introduction D: As I understand you are here because you have been having headache for the last six weeks, can you tell me more about it. P: This time it started gradually six weeks ago (so we understand that there was a pervious episode) D: Also, you have been having before? P: Yes D: For How long? Did you seek medical attention? P: If Yes D: what was the diagNosis, which treatment If No D: let’s finish your today’s headache and we’ll talk about your previous headache later. D: from that time till Now is it all the time or on and off? How often? P: Almost every day D: How long does it last each time? P: On the weekdays few hours weekend 30 min to 2 hours D: Do you wake up with this headache? P: Only on the weekend 8

9|Neurology

D: How about during the week? Do you wake up with headache? P: No D: When? P: Before I sleep. D: Where is you headache? Even the weekend? P: No D: Let’s talk about your headache in the weekdays later we’ll talk about the weekends. How does it feel? P: Squeezing D: from 1 to 10 where do you put it? Any increasing or decreasing? Did you try any pain killers? Does it help? Your headache on the weekend, where, quality, wake you from sleep, pain with your eyes, runny Nose, horner symptoms Anything brings it? Do you drink alcohol? Did you Notice any relation? Did you Notice any headache at one half of your head, any flashes, lights before your had a headache? Is it increasing by light or voice? Triggers: coffee, chocolate, cheese, red wine, lack of sleep, excessive sleep, stress, hunger, certain smells, periods, OCP, flashes light (Rule out serious conditions) any fever, chills, night sweat, lumps and bumps, loss of appetite, weight loss, head trauma, Localization: vision, hearing, buzzing sound, weakness, numbness, concentration, etc. (Because of the ddx tension r/o or confirm) are you under a lot of stress in your life? What kind of stress? How do you handle it? What do you do for the living? How do you support yourself financially? Any stress at work?

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Explore the headache before 6 weeks. Alcohol? Do you drink more? How much? For How long? Why do you drink more? P: I broke up with my girlfriend D: How is your mood? Or Do you feel depressed? Or How do you feel? If he is depressed then MIPASSECG PMHx FHx Counseling: It looks like you were going to difficult time. That caused you a lot of stress, you are under stress, this stress could sometimes cause or increase headache, you told me you’ve been having tension headache before but this time because of the stress you’re having longer and more severe attack. That could be dealt with relaxation techniques, meditation, counseling and some medication. Sometimes drinking more alcohol can trigger of headache we call it “ cluster headache”, what I recommend is you try to decrease or cut down. ( if the drinking was long cage him) that will improve your headache ( if you find depression or adjustment disorder with impact on life we should advise him: we can try antidepressant.

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24 year old, male, severe headache for 6 weeks, take history and counsel. Increase ICP Symptoms: headache in the morning, continuous, wake me up from sleep, increased with cough Causes: 1. Space occupying lesion, primary or metastasis (so we ask any history of tumor (e.g. Leukemia, lymphoma) and family history of brain tumor) 2. Infection with toxoplasmosis or abscess (ask IV drug and HIV status), HIV can cause primary lymphoma too. •

In young people we can ask directly “what is your HIV status?” or if it is overwhelming we can say, “Sometimes patients having HIV positive or AIDS might have similar type of headache. Have you ever checked or do you have any concern to be checked for HIV?”

KKKKKKKKKK Introduction: hello Mr. Davis, I’m Dr. Miller one of the physician working in the emergency room. As I understand you’ve been having headache for the last six weeks. Can you tell me more about it from the moment it started? P: my headache is increasing and it’s Not improving Dr: How did it start? Suddenly or gradually? Dr: It seems you are in severe pain do you want to lay down, can you bare with me. Dr: From that time till Now, is it all the time or is it on and off? P: it was on and off at the beginning then it’s constant. Dr: when did it become constant? Are they the same or different? P: from two weeks ago. 11

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Dr: In the beginning, How often did you have it? Was it increasing? Any certain time of the day? Was it in the morning or evening? P: morning Dr: Does it wake you up from the sleep? You told me it’s continuous; However, did you Notice any variation? Is it the first time or you’ve had it before? Where is your headache? Is it always there? How does it feel? Is it throbbing, pulsating, deep? P: Deep and dull headache. Dr: Does it shoot anywhere?

P: No

Dr: On scale from one to ten in which ten is the worst headache where do you put it Now and at the beginning? It looks like you are suffering a lot good you are hear. (Because it is continuous Noneed to ask about triggers) Dr: Anything increase it? Decrease it? How about coughing, leaning forward, lying down, lifting Dr: Anything make it better? Pain killers? Did it help or Not? Dr: How did it affect your life? (Or I can see why you are concern bare with me or How do you feel? Or what’s your expectation from today’s visit?) Dr: Any fever, night sweat, chills, weight loss, loss of appetite (if positive then when did it star? Did you measure it?) P: Yes, I have weight loss (shows headache is the manifestation of the underlying disease) Dr: How much did you lose? When? Dr: Any neck stiffness, forceful vomiting, skin rash, recent flu, or ear infection, any vision change? Any hearing problem? Dr: Any weakness, numbness in your arm or leg? Dr: Do you have difficulty with your balance? Any fall? Dr: Difficulty passing urine, change in your bowel movement, dizziness, light headedness, loss of consciousness, jerking movement, history of seizure, any mood, 12

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concentration and memory changes? Did anyone tell you that your personality had been changed? Dr: Head trauma, head injury Dr: Do you have any history of cancer, brain tumor? Any history of brain tumor in your family? Dr: Sometimes patient having HIV may present with similar kind of headache have you ever been screened for HIV? P: Yes Dr: what was the result? 1. If negative: when? P: ten years ago? then ask risk factors. 2. If positive: when, How, did you receive treatment? When was the last time you had follow up visit? what was your CD4 count? P: I stopped because of side effect of drugs D: what kind of side effect did you have? What was your last CD4 count. (If he was diagNosed Noneed for risk factors, if he wasn’t diagNosed go for risk factors: drug, homosexuality, and ask about symptoms of HIV: weight loss, chronic diarrhea, chest infection, cough, TB, skin changes, ulcer in the mouth, burning sensation (heartburn)) Social history (because it is related we ask it here) Dr: Drug, with whom do you live? Med Hx: Any medicine, allergy? PMHx: Hospitalization, any surgery, any other condition? Counseling: Mr. Davis, any question before I proceed? We need to do some physical exam and blood work and imaging for your brain. However, based on your symptoms it sounds concerning for that reason, we need to admit you today. Because you stop your medication you may be vulnerable to have some kind of infection related to HIV virus. We might use some medication, antibiotics, to treat it and it is important you’ll be seen by infectious disease specialist. Make new combination to decrease your side effects. Any question? Thank you.

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35 year old female headache six weeks clinic Hx and counseling Presentation for domestic violence: 1.Headache 2.Abdominal pain 3.Insomnia 4.Sleeping pills 5.Vaginal bleeding

KKKKKKKKKK Introduction, Open ended question (Usually they don’t have good eye contact and pain is vague and patient is Not cooperative) D: How did it start? P: I can’t remember, gradually D: Anything specific at that time? P: No D: from that time till Now, is your headache all the time or on and off? How often do you have it? How long does it last? Where is it? Does it shoot anywhere? How does it feel? Severity? Anything increase it, decrease it? P: more on the weekends. D: anything change in the weekends? What happens on the weekends?

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Constitutional sx (quick primary headache) Transitional: I want to ask you some questions about your social life. D: with whom do you live? P: my children and my husband. D: How do you support yourself financially? Any change in your life? Any stress? (Confidentiality) I’d like you to kNow our relation is extremely confidential, whatever you tell me it’s going to be confidential; we do Not release any information without your permission, unless otherwise I’m asked by the law. (Go for something else after confidentiality and come back later) PMHx How is your mood? Interest? (To rule out or confirm depression) Smoking, alcohol, drug M P: ….. my husband D: How is your relation with your husband? 1. Is your husband going through a lot of stress? Did he change in his life? Does your husband drink? Does he drink more Now? Does he drink to the extend he lose control and get angry? 2. If he is under stress, How does this stress affect his life? Does he get angry? Do you have more argument, recently? Does he get angry?

When he gets angry, what does he do? Does he start to shout? Does he shout at you? Does he swear at you? Does he call you names? does he try to put you down? How does it affect your self-esteem? Did he ever get angry? Did he ever get angry to the extent that he became physical? Has he ever hit you or pushed you? Did you visit emergency room? How many times? Was there any serious consequence? Does he ever force you to have sexual activity against your will? Who control spending at home? 15

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Do you have access to bank account? Did he ever mistreat you in front of the children? (If Yesbecause of emotional abuse to the children inform child society) Have you ever thought of ending your life or his life? Do you have access to weapon at home?(Support) Do you bring it to somebody you trust? Did you talk to anybody? Any member of the family or who you trust? Counseling: 1. She wants to get helped 2. She doesn’t like to leave but accepting help 3. She doesn’t want help and support the abuser 1. I’d like you kNow, based on what you told me, what you are experiencing is called “domestic violence” or “spouse abuse”. And it’s illegal, it’s a crime against law and unacceptable, and you shouldn’t tolerate it. And it’s Not your mistake; you haven’t done anything to deserve that. And you shouldn’t feel guilty. And we kNow from the studies the situation will deteriorate without help. Thing will go out of hand. For that reason, we recommend that you call police to arrest him. P: he is a financial provider for us! What will happen to us? D: being a mother with children and being domestic violent victim you have priority. You have support from the community. There are resources, I’ll give you phone number for help groups. They will help you with housing, financial support for yourself and you children. Later they will help you to start your life again. 2. P: he is a good man. D: ok. I can see. That could be the situation. As I told you the situation will Not improve and this the vicious-cycle. The more you stay together the more abuse would be there. My fear is that thing will get out of hand. We kNow from the studies if you involve the police by court they will push him to get help and treatment (don’t let her call the police from your office) 3. P: I like him, he is the best. He is great. D: If you go back home Now, do you feel safe? What if thing get out of hand? I recommend you prepare a bag and put your essential needs, some money and document. Put it in a place in case you need to leave, you can immediately take. I’d like to see you in 3 days. But you can always call the police. Once they arrest him and put under chare, the court put him on some kind of rehabilitation and probation.

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A case of carpal tunnel syndrome (CTS)

Dr : Hello, good afterNoon. Mr Douglas. I am Dr Miller. I am one of the physicians working in the clinic today. As I understand you are here because you have pain in your right hand for the last 6 weeks. Can you tell me more about it from the time it started? (we asked CC and asked open ended questions) Patient: For the last 6 weeks I have been having increasing pain in my right hand which is Not improving. Dr : OK, I see. Did you seek any medical attention before? Any doctors? Patient: No Dr : What motivates you to choose to come today? Patient: Nothing (or may tell you because of starting of weakness) Dr : How did it start? it started suddenly or gradually? Patient: It started gradually. Dr : From that time till Now it is all the time or it is on and off? Patient: It is on and off. Dr : How often you have it? Patient: Almost every day. Dr : How often at the beginning? Patient: Less often, but it is more Now. (We establish that it increases in frequency. ) Dr : What is the duration of each attack? Patient: few seconds to minutes. Dr : What brings its attack (we want to kNow the relation to position or movement)?

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Patient: I have it at work. Dr : What do you do for living? Patient: I am a carpenter (Show empathy) Dr : How did it affect you? Are you still able to work? Are you missing some days of your work? Good you are here today. Hopefully we will be able to deal with your pain. Is it more in night or in day? (PQRST) Show me where is the pain? How does it feel? Patient: it feels like an electric shock Dr : Does it shoot anywhere? Dr : What is the severity in scale of 1 to 10? Did you take any medication? What makes it better or worse? Associated symptoms: Any swelling? any redness, skin changes, burning, tingling , numbness, weakness. (when it reaches weakness it needs surgery.) What about the other hand? Differential diagnosis: (C6 radiculopathy) Dr : any neck pain, neck trauma, relationship between moving your neck and pain in your hand? fever, night sweat, chills, lumps, bumps, loss of appetite, weight loss?

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Dr: I am going to ask questions about risk factors. We have to ask about diseases and their symptoms. Dr : Now I am going to ask about some conditions to see if you have any medical condition that may explain your pain. (Hypothyroidism) Do you have any history of thyroid disease? (If he tells No, then) Do you feel cold, if everybody is feeling fine? Do you have any constipation or dry skin? Do you have any history of any trauma to your wrist or fall? Do you have any history of rheumatoid arthritis? skin rash? Do you have any history of Diabetes? Drinking more? eating more? peeing more? going more to the washroom? Do you have any history of Acromegally? Do you Notice that your rings are getting tight? Your shoes are tight? If you wear gloves and hats, do you find they are getting tighter? Next time bring me a photo of yourself that you were ten years younger. (If patient is a woman) Are you pregnant? (medications such as steroids) Any medication? (Amyloidosis)

What do you do for living (if you did Not ask before. Some jobs such as Jackhammer are prone to CTS.) Any job with repeated movement of the hand? ( Then we go to PMHx and FHx)

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40 Y/O female, RT. Arm weakness for the last 6 hours in ER:

Dr : Hello, good afterNoon. Ms. Greenwood. I am Dr Miller. I am one of the physicians working in the emergency room today. As I understand you are here because you have weakness in your right hand for the last six hours. Would you please tell me more about it from the moment it started? Patient: This morning after I had my hot shower and when I was preparing my breakfast, my arm dropped suddenly. Dr : Did you burn or hurt yourself? Patient: No. Dr : OK. How did it start? Suddenly or gradually? Patient: Suddenly. Dr : And from that time has it been on and off or all the time? Patient: Nodoctor. All the time. Dr : When you say weakness, what do you mean? Can you move your arm at all or you find it is difficult than before (severity of weakness)? Dr : Where is the weakness: hand, arm or your shoulder? Dr : Any numbness, tingling in your hand? Dr : Any weakness, tingling or numbness in the right leg or left hand and leg Now? Dr : Any weakness, tingling or numbness in your legs or hands before? If patient answers yes, then ask her: How long it lasted and was there full recovery? Dr : With this weakness, do you find any difficulty finding words, or anybody tells you it is difficult to understand you? Have you had at any times including today any complaints such as: any change in vision (if says yes, you have to clarify How many times, what does she mean by it such as blurred vision, double vision and if any change in vision in warm places like taking hot showers), difficulty in hearing, buzzing sounds in your ears, difficulty swallowing, difficulty with balance and falls, difficulty in urination (sometimes when patients have these symptoms they may Notice changes in their urination or even in their bowel movements or they might loose control of their urination or bowel movement. Have you ever experienced these?) 20

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Dr : Any dizziness, light-headedness, headache, jerky movements, loss of consciousness, seizure? When you bend your neck, is there any electric shock along your spine (Lhermitte sign)? Any electric shock or pain in your face when shaving your face (male) or chewing or eating (trigeminal neuralgia)? Dr : Any change in mood? Memory? concentration? Any change in your personality? Any changes in your symptoms and hot place (Uhthoff pheNomeNon)? Dr : (Now we ask for constitutional symptoms) Any fever, night sweat, chills, lumps, bumps, loss of appetite, weight loss? Dr : (Now we ask for ROS from head to toe) Any chest pain, heart racing, shortness of breath? Cough, wheezing, phlegm, chest tightness? Abdominal pain, heart burn, nausea, vomiting, bowel movement? Flank pain, urine changes, burning sensation, frothy urine, going more to the washroom, and loose of control? Any yellow discoloration of skin, itchiness, and pale stool? joint pain, joint swelling, skin rash, ulcers? red eyes? Anybody told you are pale? bleeding from anywhere, your Nose, your gum, bruises in your body, coughing blood? Do you feel cold or hot when everybody is fine? (thyroid) Do you feel any dry or moist skin, shakiness, constipation, weight gain? (Diabetes) Do you drink more, going more to the washroom, do you feel tired? (Always when asking for anaemia in females ask for) When was the last period? Heavy? Regular? PMHx? FHx of multiple sclerosis, stroke?

If a patient with a chronic condition (like MS) states that if later in life he/she becomes unconscious and needs ventilation, do Not ventilate him/her and on the time of decision he/she was competent, then Now what should we do if the patient looses consciousness and needs ventilation? Answer: We have to respect her decision (because she made the decision when she was competent) and do what the patient asked before.

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67 Y/O male, RT.arm weakness from 45 min ago:

Dr .: Hello, good afterNoon. Mr Douglas. I am Dr Miller. I am one of the physicians working in the emergency room today. (You are starting to shake his hands but may Not be able to do it because of his weakness). As I understand you are here because you have weakness in your right hand for the last 45 minutes. Would you please tell me more about it from the moment it started? Patient: Yes, Doctor, what do you want to kNow? Dr .: How did it start? Suddenly or gradually?

Patient: Suddenly.

Dr .: What were you doing? Patient: I woke up. I was preparing my tea pot, that my arm dropped or I was holding the tea cup that my arm dropped. Dr .: Did you harm yourself? Did you burn or hurt yourself? Dr .: Were you sitting or standing? Did you fall down at that time? From that time is it all the time or on and off? (You can ask if it was the first time or you had other episodes before. You can ask this question later.) Dr .: When you say weakness, what do you mean? Is it completely weak or you can move it with the grip Not as strong as before? Dr .: Where is this weakness? Is it in your hand, arm, How about your shoulder? Dr .: How about any tingling, numbness? In addition to weakness in your right arm do you have any weakness in your right leg? (If he says: yes, then did they start together? same time or different time? Which one is weaker? Which one bothers you more? your arm or your leg?) (if he says: I have weakness in my leg, tell him: were you able to walk? were you dragging you foot? How about your balance?) Dr .: How about your left arm or your left leg? Dr .: Is it the first time it happened to you or you have it before? Patient: No, it is the first time. 22

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Dr .: At that time, were you alone or with someone else? Patient: I was with my wife. Dr .: Did she tell you it was difficult to understand you? Or did you fine it difficult to find words? (then you have to check for other neurologic symptoms.) Dr .: Do you have any headaches? dizziness? jerky movements? loss of consciousness? (then to check if any involvement of face) Dr .: Did you feel any food stuck in your cheek? Did you feel any numbness in your face? (then we go for the rest of neurologic symptoms) Dr .: Loss of vision or curtain (falling in front of eyes) or blurred vision? hearing (difficulty) or buzzing sound? Difficulty swallowing? difficulty in balance? difficulty in passing urine or change in bowel movement? How is your memory/concentration recently? How is your mood recently? (to rule out any malignancy) Any fever, night sweat, chills, lumps, bumps, loss of appetite, weight loss? Risk factors: Dr .: Any history of high blood pressure? high blood sugar? high blood cholesterol? sugar and cholesterol measured or Not? smoking, alcohol, recreational drugs? Any history of heart attack or disease? Any history of stroke or heart disease in young age in your family? Have you ever diagNosed as having atrial fibrillation? Any history of heart racing? (in this case) Patient: yes. Dr .: For How long? is it regular or No? Can you tap it for me? (if he says No, it does Not exclude it. You can find it with physical exam and ECG.)

Dr .: Do you remember you have any head trauma/injury? Do you take any medication like blood thinner?

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1|OB/GYN

OB/GYN Counseling: 1. Urgent Antenatal Visit Case: 39 Y/O female came to the clinic because she found that she is pregnant last night.Next 10 m. take Hx and counseling. (she asked for urgent meeting). Role- play: (some important phrases) Pt. has concern about her age + pregnancy. She asks if Dr. can make sure that the baby is healthy 100%, otherwise she wants abortion. Whenever you take Hx: always you should ask about concerns answer take Hx In above case you need to take hx before addressing her concerns. She is worry about down syndrome. Why she is worry about it. When you take hx go for Menstruation: LMP-Preg.test -Preg.sx.(in Canada repeat preg.test) Gynecology.4 questions , Obstetric, Sexual.1 question PMH: you look for RF FHX: you look for congenital anomalies Education advise We have some screening tests for congenital anomaly.

Amniocentesis When

14-16 wk

Accuracy

99.97%

Risk of abortion +

CVS 10-11 wk 97.% 3% false neg.

1/200=0.5%

1/100=1-2%

Risk of fetal limb inj Results take

2wk

48h

CVS is not accurate & risk of abortion is higher. .At age of 35 the chance of having baby with congenital anomaly is 1/180 half of 1

2|OB/GYN them are Down sy = 1/365 The chance keep increasing when we get older. At age of 45 the chance of having child with Down syndrome alone is 1/20=5%. The chance of abortion after Amniocentesis is 1/200=0.5% is smaller than the chance of having kid with congenital anomaly at age of 35 which is 1/180=0.55% 0.5%