* History Taking

* Physical Exam
* Important Miscellaneous stuff
CASES:
! "# $r% &'( Complaining of A)*ominal Pain
2) 27 Yr. O/F complaining of rash
"! +, $r &l* -a*y .ith arm an* leg .eakness%
/! 01 $r% &'( kno.n sickle cell anemia pt c'o chest pain
,! 0, $r% &'M complaining of cough
+! /# $r% &'M complaining of fatigue an* loss of .eight
2! "# $r% &'M came to HI3 *rug refill
4! ", $r% &'( Came for e5aluation of 6aun*ice
1! 0+ $r% &'M Complaining of 7iarrhea
#! ++ $r% &'M complaining of constipation
! /# $r% &'M Complaining of Impotence
0! Mother of $r% &'8a)y 9ith (e5er
"! /, $r% &'( Complaining of acute a)*ominal pain in :t upper ;ua*rant
/! 0/ $r% &'( Came for prenatal 5isit for the first time
,! +# $r% &'M Complaining of shortness of )reath
+! /# $r% &'( .ith no energy an* increase* urination
2! 0,$r% &'( Complaining of sore throat
4 ! ", $r% &'( Complaining of Chest Pain
1! /, $r% &'M complaining of :t lo.er a)*ominal pain
0# ! /# $r% &'M Complaining of -eg Pain
0! /# $r% &'M Complaining of 3omiting of 8loo*
00! ,, $r% &'M Complaining of Chest Pain

0"! 2# $r% &'M complaining of (re;uent (alls

0/! ", $r% &'M Complaining of Cough an* Chest Pain
0,! +# $r% &'M Complaining of lo.er a)*ominal pain
0+! +, $r% &'M re;uesting pain me*ication
02! "0! +, $r% &'( Complaining of -oss of Hearing
04! +0<year<ol* man .ith fre;uent falls
01! A ,# year<ol* man .ith )lurre* 5ision
30) 32 yr old female with multiple bruises
"! $oung female complains of )urning urination
"0! A +, yr ol* male .ith *ifficulty s.allo.ing
""! ,0yr &l* Male Pt for 8P Check an* refill
"/! + years ol* .ith amenorrhea
",! ", yr ol* female .ith acute lum)ar an* )ack Pain
"+! 20 yr ol* .ith insomnia
"2! +, yr ol* male patient .ith *ifficulty urinating
"4! /, yr ol* complains of )reathlessness an* anxiety%
"1! ," yr ol* .ith a long history of epigastric pain
0) ! yr old complains of bloody "omitings
#) $0 yr old male pt complains of %i&&iness
/0! "# yr ol* male .ith ne. onset of sei=ures
3) ' 23 yr old male with rectal bleeding
//! ", yr ol* complains of fatigue
/, ! A ," yr ol* male .ith right knee pain an* s.elling
&ther interesting Cases :
! /#<year<ol* .oman .ho has )ecome .ith*ra.n
0
0! ,0 &'( .ith a Complaint of hot flashes
"! 2# $r% &'( Complaining of (orgetfulness
/! ,# $r% ol* *ia)etic male came for me*ication refill
,! 0# $r% &'( Complaining of 5aginal )lee*ing
+! ,+ year ol* Man comes .ith left si*e* shoul*er pain
2! A /# yr ol* .hite female came for o)esity e5aluation
4! A +1 yr ol* male .ith terminal cancer re;uesting for pain me*ications
1! A +0 yr ol* male .ith confusion
#! A 0, yr ol* male for pre<employment check up
! Case of A)use
0! Patient .ith Insomnia
"! A +, yr ol* la*y .ith 7i==iness
/! Heel pain >&r! (oot pain
,! -o. )ack pain
+! A 0, yr ol* female .ith nausea an* 5omiting
2! A "/ $r &'( came for 8ronchial asthma *rug refill
History Taking
The most *ifficult part of the exam is time maintenance% $ou ha5e to *o e5erything in , minutes% So to
make e5erything in , minutes .e ma*e a 5ery goo* proforma to pass in this exam%
Intro*uction an* greeting:
Hello Mr% xy=? goo* morning or goo* afternoon? I am 7r% xy=? it is nice to meet you >shake han*!%
@ext ask < A9hat )rings you to see me to*ayA or A9hat )rings you to come in to*ayBA%
Then the SP .ill tell you the chief complaint >C%C!
Then ask one open en*e* ;uestion < ACoul* you please *escri)e me .hat exactly is going on or more a)out
your pro)lem%A
"
Then he .ill tell you only minimal )ut some extra history? )ut remem)er he .ill ne5er tell you the important
facts that you ha5e to ask%
Then you ha5e to procee* like this
(ocation)
(irst thing that you ha5e to keep in min* is: A9here is the pro)lemBA >ACan you please sho. me .here
exactly the pain'pro)lem isBA!% If the C%C is a pain you can ask ACan you sho. me the exact spot .ith your
fingerBA%
Onset * duration)
Al.ays ask for the onset an* *uration of the pro)lem% So that you can kno. .hether the pro)lem is acute or
su) acute or chronic%
7uration: Ex% A9hen *i* it first start or .hen *i* you first noticeBA 7epen*ing upon the complaint%
If the C%C is chest pain < A9hen *i* it first startBA
If the C%C is 5aginal *ischarge < A9hen *i* you first noticeBA
Then ask a)out the onset A9as all of su**en in onset or progressi5eBA
Then you ha5e to ask follo. up ;uestions regar*ing the C%C <
+ntensity)
Al.ays one shoul* ask a)out the intensity or se5erity of the pro)lem especially if the complaint is pain%
Ex% AIn a scale of to#? if is the least painful an* # is the most painful? .hich num)er .oul* *escri)e
your painBA &r AHo. .oul* you gra*e your pain on a scale of to #BA
:emem)er they alrea*y kno. some me*ical kno.le*ge? they .ill imme*iately tell you the num)er% Cust ask
like that%
If the chief complaint is not a pain you can assess the se5erity )y asking ;uestions like these% AHo. )a* is
itBA? A7oes it interfere .ith your *aily acti5itiesBA? A7oes it *istur) your sleepBA%
,uality)
Duality of the pain may tell you the pro)lem like )urning type of pain in aci* peptic *isease an* EE:7%
Ex% AHo. .oul* you *escri)e your painBA or A9hat *oes it feel likeBA AI mean is it crampyB sharpB
thro))ingB )urningBA
Fre-uency)
Al.ays ask a)out ho. fre;uent the pro)lem isB
Ex%A Is it constantBA or A7oes it come an* goBA% If it is intermittent? AHo. often *oes it occurBA? AHo. long
*oes it lastBA% AHo. *o you feel )et.een attacksBA%
.adiation)
This is usually aske* if the complaint is pain%
Ex% A7oes it mo5e any.hereBA or AHas it change* locationBA
'ggra"ating * precipitating factors)
$ou may get a clue from aggra5ating an* precipitating factors like if ha5ing foo* aggra5ates the epigastric
pain i%e% most likely a gastric ulcer%
Ex: A9hat .ere you *oing .hen it first )eganBA? AHa5e you e5er foun* anything that makes your
pro)lem'pain .orse or )a*B
/
Ex0: A7o you ha5e any i*ea of .hat might ha5e )rought this onBA or A9hat )rings it onBA%
.elie"ing factors /alle"iating) factors)
Along .ith aggra5ating an* precipitating factors this .ill also help you in making *iagnosis in certain
con*itions like ha5ing foo* .ill relie5e pain in *uo*enal ulcer%
Ex% AHa5e you e5er foun* anything that makes your pain or pro)lem )etterBA? Continue AHa5e you treate*
yourselfBA? AHas the treatment helpe*BA%
'ssociated problems)
Here again you can ask one more open en*e* ;uestion%
Ex% 7o you ha5e any other pro)lems that you .oul* like to tellB >or! 7o you ha5e any other symptoms
)esi*e AChest PainA etc%B
9hen you ask the SP like this? the SP may ask you A-ike .hatBA ThatFs .hy you ha5e to continue .ith all
the pertinent positi5es an* negati5e symptoms%
(e5er:
If you think the symptoms are *ue to infectious origin? or the suspecting con*ition is associate* .ith fe5er
you ha5e to ask a)out the fe5er%
A7o you ha5e fe5er01 or 1Ha5e you ha* fe5ersBA
If yes then AHo. long ha5e you ha* fe5erBA
AIs it a continuous or intermittent fe5erBA
AIs'9as it associate* .ith chills? is'.as there any s.eatingBA
Cough:
A7o you ha5e a coughBA
AIs it a *ry cough or pro*ucti5e coughBA or A7o you )ring up sputumBA
If it is pro*ucti5e then A.hat color is'.as itBA
AIs'9as there any )loo* in itBA
AIs'9as it foul smellingBA
AHo. much is'.as itBA AIs it a tea spoon or ta)le spoon or a cupfulBA > for ;uantity assessment al.ays use tea
spoon? ta)le spoon an* a cupful% E5en for )lee*ing per rectum !%
In all chronic cough patients *onFt forget to ask a)out HI3 status an* tu)erculosis% They .ill not tell you
until you ask a)out his HI3 status*%
$ou shoul* also ha5e to ask a)out *rug intake especially a)out the use of ACE inhi)itors*%
Shortness of )reath:
AHa5e you e5er ha* any pro)lems .ith your )reathingBA? AHa5e you )een .hee=ingBA >They kno. .hat is
.hee=ing!%
AHo. far *o you .alk on le5el groun* .ithout ha5ing )reathing pro)lemBA? A7o you ha5e to stop to rest to
catch your )reathBA
AHa5e you ha* any attacks of )reathlessness in the nightBA >P@7!
A7o you nee* to sit<up to ha5e asleepBA >orthopnea! or A7o you ha5e trou)le lying flat in )e*BA%
@ausea an* 5omiting:
AHa5e you felt nauseate*B'7o you feel nauseate*BA
AHa5e you ha* 5omitings or *i* you thro. upB A
If yes then AHo. many timesB 9hat *oes the 5omitus look likeB 9hat color .as itB 9as there any )loo*BA
,
Ask the nature of 5omiting like pro6ectile etc%
Hea*ache:
A7o you ha5e any hea*acheBA
E*ema:
A7o you ha5e any pro)lems of s.elling of arm'legsBA or A7o your ankles s.ellBA
If yes ask A .here *i* you notice it firstB .as it on the face or legBA
Ask them a)out any *iurnal 5ariation > AIs the s.elling more *uring morning or e5eningBA!
Thyroi*:
AHa5e you e5er ha* pro)lems a*6usting to temperaturesBA
AIs there any change in your 5oice recentlyBA >hoarseness in hypothyroi*ism!
AHa5e you notice* any change in your )o.el ha)its recentlyBA >constipation in hypo an* *iarrhea in
hyperthyroi*ism!
AHas your .eight change* any.ay latelyBA
2ast 3edical 4istory)
Here .e gi5e you an example of ho. to elicit past me*ical history >This .oul* mainly gi5e you an i*ea of
ho. to frame ;uestions an* sa5e time!%
$ou ha5e to use transition sentences often *uring this part of history taking% 8elo. is an example of a
transition ;uestion >you .oul* tell the patient a)out .hat you are going to ask instea* of *irectly 6umping
into other topic!
Example: G&k Mr% 8ro.n no. I .oul* like to ask fe. ;uestions regar*ing your past me*ical health% Is that
ok .ith youBA%
2re"ious episodes of chief complaint)
Ex : AHa5e you e5er ha* similar pro)lems in the pastBA%
'llergic history)
8ear in min* that most of the SPs ha5e some sort of allergic history though it is not relate* to the chief
complaint% Therefore you ha5e to take the allergic history% >In )rief if the patientHs complaints are not mainly
relate* to allergy like case of menopause? psychiatric caseI%! Cust ask GAre you allergic to anythingBA or
A7o you ha5e any allergiesBA%
If the case is relate* to allergy? > C'& Shortness of )reath? rash? arthritisI%% ! then you can elicit the history in
the follo.ing .ay: GAre you allergic to petsB >Ei5e a pause an* ask for the next allergen! 7rugsB Any
specific foo*sB Col* an* *ust allergyBJ
If the SP gi5es you any positi5e history then ask follo. up ;uestions: Start off .ith an open<en*e* ;uestion
like: JCoul* you please *escri)e more a)out your allergic pro)lemBA
If he *oesnHt open up properly then ask the follo.ing ;uestions G Ho. often *o you get allergic episo*esB
Are you taking any me*ication for thatB 9hat kin* of allergic reactions *i* you ha5eBA
3edical problems in the past)
In general for any case you .ill ha5e to ask history of high )loo* pressure >*o not use me*ical terminology
like hypertension! an* *ia)etes >this is accepte*!%
In cases relate* to specific systems the follo.ing ;uestions are to )e aske*:
+
567 < AHa5e you e5er ha* any strokeBA A7o you ha5e any history of migraine hea*achesBA AHa5e you e5er
ha* any sei=uresBA%
587 < AHa5e you e5er ha* heart pro)lems like heart attack or heart failureBA
.7 < AHa5e you e5er ha* tu)erculosisBA? A7o you ha5e a history of asthmaBA? AHa5e you e5er ha* any lung
pro)lemsBA
9+: ; AHa5e you e5er ha* stomach pro)lems or ulcersBA? AHa5e your e5er ha* any pro)lems .ith your
gall)la**er or li5erBA%
.<6'(; AHa5e you e5er ha* any history of ki*ney infectionsBA AHa5e you e5er ha* any ki*ney stonesBA?
AHa5e you e5er ha* any pro)lems .ith your prostateBA
:4Y.O+% 2.O=(<37 >@e5er forget to ask a)out thyroi* as many cases >Ex: SP .ith C'& .eight
loss'.eight gain? 7epression? Amenorrhea etc! are relate* to thyroi*% They .ill )e rea*y to tell you if you
6ust ask them% They might also gi5e you *irectly the name of the *isease%% like HashimotoHs Thyroi*itis?
Eoiter etc%
5ancers ; AHa5e you e5er *iagnose* .ith any type of cancerBA%
4ospitali&ation)
Ask a)out any past h'o hospitali=ation? trauma an* h'o surgeries%
AHa5e you e5er )een hospitali=e*BA? 9hat forBA A9henBA%
AHa5e you e5er ha* any surgeryBA? A.hat forBA A9henBA%
AHa5e you e5er )een in5ol5e* in a serious acci*entBA? A7i* you )reak any )onesBA? A7i* you ha5e any
serious hea* in6uryBA%
>rinary complaints)
If the case is not relate* to urinary system 6ust ask : GHa5e you ha* any pro)lems .ith your urination BJ or
A7o you ha5e any trou)le .ith your urineBA
If relate* to Eenitourinary system the take a *etaile* history%
H'& 8urning micturition >AHa5e you ha* pain or )urning .hen you urinateBA!
H'& Krgency >F7i* you e5er ha5e to rush to urinateBA!
H'& (re;uency'@octuria >AHo. often *o you urinateB 7o you .ake up in the nights to urinateBA!
H'& Hesitancy >A7o you ha5e any hesitation to urinateBA!
H'& Hematuria >A7i* you notice any )loo* in your urineBA!
H'& Pyuria >A9as there any pus in your urineBA!
H'& Straining >A7o you ha5e to strain *uring urinationBA!
Changes in stream of urine >AHo. is your flo. of urineB Is it continuous or is there any *ri))ling after
urinationBJ!
H'& Incomplete emptying >A7o you feel fullness of )la**er e5en after passing urineBA!
H'& Incontinence >AHa5e you e5er passe* urine .ith out your kno.le*geBA!
9astro intestinal problems)
If the case is not relate* to EIT then 6ust ask: G Ha5e you e5er ha* any pro)lems .ith your )o.el
mo5ementsBJ
AHo. often *o you mo5e your )o.elsBA
AHa5e your )o.el mo5ements change*BA
AAre they har* or softBA A9hat consistencyBA A9hat colorBA
AHa5e you notice* any )lack or tarry stoolsBA
7leep)
En;uire .hether he has any pro)lem .ith his sleep >G7o you ha5e any pro)lem .ith your sleepBJ!
2
If so ask .hether he has *ifficulty falling asleepB &r maintaining sleepB &r early .akeupB
This is mainly re;uire* in all psychiatric cases%
Family 4istory)
8efore taking the history let the patient kno. that you .oul* )e asking him a)out his family health? i%e%? pose
a transition ;uestion%
G&k Mr% 8ro.n no. I .oul* like to ask fe. ;uestions regar*ing your familyFs health? Is that ok .ith youBJ
An* continue as follo.s:
G7oes any one in your family ha5e similar pro)lemsBJ
GAre your parents li5ingBA
If SP says $ES? then ask AHo. is their healthBA
If SP says @&? sho. some empathy like G&hL I am sorry to hear that? Coul* you please tell me the cause of
their *eathBA
If necessary ask for the family history of *ia)etes? high )loo* pressure? stroke? heart pro)lems%
Obstetric and 9yn 4istory)
8efore taking the history let the patient kno. that you .oul* )e asking a)out her &)stetric an*
Eynecological history%> So you .ill )e posing a transition ;uestion here%!
G&k Mrs% Smith no. I .oul* like to ask fe. ;uestions regar*ing your gynecological health? Is that ok .ith
youBJ? continue as follo.s:
If it is not a &)stetrical'Eynecological case 6ust ask :
% G9hen .as your last menstrual perio*BJ%
0% GAre'9ere your cycles regularBJ%
If it is a &8'Eyn case en;uire a)out
Menarche AHo. ol* .ere you .hen you ha* your first perio*BA
AAre your perio*s regularBA
AHo. many *ays *oes your perio* lastBA
AHa5e you e5er )lee* )et.een cyclesBA
AHo. many pa*s *o you use in a hea5y *ayBA
A7o you ha5e a)*ominal cramps'pain .ith your perio*sBA
A7i* you e5er notice any )lee*ing after intercourseBA
A9hen .as your last menstrual perio*BJ
3aginal *ischarge:
AHa5e you e5er ha* any 5aginal *ischargeBA
If $ES? then ask G9hat is the color of the *ischargeB 7oes it ha5e any )a* o*orB 7o you ha5e any 5aginal
itchingBA
AHa5e you ha* any sores or infections aroun* the 5aginaBA
Pregnancy:
GHa5e you e5er )een pregnantBJ% AHo. many timesBA? AAny miscarriages or a)ortionsBA%
If $ES GHo. many times *i* you a)ortB In .hich month'.eek of your pregnancyB 7o you kno. the reason
>s! for the a)ortionBJ
AHa5e you ha* any other pro)lems or complications .ith the pregnanciesBA%
AHo. .ere the )irthsBAA Ha5e you ha* any complications *uring *eli5eryBA%
A)*ominal pain:
4
GHa5e you e5er ha* any pain in your )ellyBJ
If $ES continue .ith all the ;uestions gi5en un*er pain in present history
Pap smear:
AHa5e you )een getting regular pap smearsBA? A9hen *i* you ha5e the last Pap smearBA%
7e?ual 4istory)
8efore taking the history let the patient kno. that you .oul* )e asking a)out her'his sexual history? so you
.ill )e posing a transition ;uestion% > &k Mr% 8ro.n @o. I .oul* like to ask fe. ;uestions a)out your
sexual history? please un*erstan* it .ill )e kept confi*ential )et.een you an* Me? I%try to )e as honest as
possi)le% Is that ok .ith youB ! Continue as follo.s:
GAre you sexually acti5eBJ
If $ES G9ho is your sexual partnerBA? A7o you ha5e any other sexual partnersBA or A7o you relate sexually
to men? .omen or )othBA? GAre you satisfie* .ith your sexual lifeBA
If @& en;uire the reason? A7o you ha5e any pro)lems in your sexual lifeBJ A AAny loss of interest in sexBA?
AAre you a)le to reach a orgasmBA
G7o you use any means of contraceptionBJ
If $ES G9hat type of contraception *o you useB 7o you use it regularlyB
(or high risk groups like patients .ho are not using )arrier metho*s of contraception? patients .ith multiple
sexual partners? patients .ith homosexual history continue .ith follo.ing ;uestions: >@ote: most of the time
they ha5e this history an* so ne5er miss it%
GHa5e you e5er )een teste*'treate* for sexually transmitte* *iseasesBJ
GHa5e you e5er )een teste* for HI3BJ
7ocial history)
$ou nee* to pose a transition ;uestion: >G&M Mr% 8ro.n no. I .oul* like to kno. a)out your social ha)its
an* personal life style? is that ok .ith youBJ!
Appetite:
AHo. is your appetiteBA
7iet:
ACan you please tell me a)out your *ietA
J9hat *oes your *iet mainly consistBJ
AAre you on a special *ietBA
(or peri'postmenopausal .omen ask A7o you take calcium supplementsBA%
9eight:
GHas your .eight change* any.ayBJ
If $ES: GHo. muchB In .hat perio* of timeBJ
Smoking:
G7o you use to)accoB 7o you smokeBJ
If @& GHa5e you e5er smoke* in the pastBG >Most of the SPHs ha5e past history of smoking!
If $ES GHo. many packs *o you smoke per *ayB (or ho. long ha5e you )een smokingBA
AHa5e you e5er thought a)out ;uitting'attempte* to ;uitBA
1
Alcohol:
G7o you *rink any type of alcoholic )e5eragesBA
If @& GHa5e you e5er consume* alcohol in the pastBG
If $ES G9hat type of )e5erage *o you takeB Ho. much *o you *rink per *ayB AHo. long ha5e you )een
*rinkingBA
Al.ays keep in min* a)out the 5'9< ;uestionnaires for suspecte* alcohol a)use cases > Ex% upper EI
)lee*ing? :ight upper ;ua*rant pain? epigastric pain%!
AHa5e you e5er trie* to cut *o.n on alcohol *rinkingBA
AHa5e you e5er )een annoye* )y other people for your *rinkingBA
AHa5e you e5er ha* guilty feelings a)out your alcohol *rinkingBA
A7o you *rink alcohol early morningBA
7rugs:
AAre you currently taking any type of o5er the counter me*icationsB any prescription me*icationsBA
AHa5e you e5er trie* any recreational type of *rugsBA
If $ES to any of the ;uestions ask G9hat kin* of *rugsBA? AHo. long ha5e you )een taking themBJ? AHa5e
you e5er in6ecte* *rugsBA%
&ccupation N exposure:
G 7o you .orkB 9hat type of .ork *o you *oBA? AIs it a stressful 6o)BA > Analy=e .hether it is mentally '
physically stressful Ex: mental< 7epressionO physical: carpel tunnel syn*rome > key )oar* users !%
AAre you expose* to any health ha=ar*s in your .ork or personal lifeBA
AAre your .ork con*itions safeBA
A7o your 6o) in5ol5e prolonge* sun exposureBA > for a case of rash!
A7o you expose to lou* noises at .orkBA >for a case of hearing loss!
Exercise:
A7o you exercise regularlyBA
Stress:
A7o you ha5e any stresses from your familyBA
Tra5el:
AHa5e you tra5ele* outsi*e the Knite* states in the resent yearsBA? A9henBA? A9hereBA%
7pecial 7ituations)
Angry Patient:
AMr% xy=? you seem to )e 5ery angry? coul* you please tell me .hy that is soB Is there any
.ay that I can help you%A
Kncooperati5e patient:
AMr% P$Q I can un*erstan* your pro)lem? )ut to properly un*erstan* your pro)lem? I ha5e
to *o this test% It .onFt take more than a minute% I am here to assist you% okBA
#
Pain in han*:
A7oes your 6o) in5ol5e repetiti5e han* mo5ements like key )oar* operation%A >Carpal tunnel
syn*rome!%
Insect )ite:
A7o you remem)er )eing )itten )y any insects like ticks an* mos;uitoesBA> for any rash
case!
Trauma patient:
Some times you may get a patient .ith trauma or ro))ery etc% They .ill act like any thing
an* you can see all the )ruises in *ifferent colors .ith goo* painting% The main issue .ith these
patients is *onFt repeat the painful maneu5ers% Some times they may .orry a)out their social
situation >money!% (or example a chest trauma patient from ro))ery .ho ha5e signs an* symptoms
of hemothorax *onFt .ant to get chest <P <ray )ecause he *oesnFt ha5e insurance% So in those cases
explain like this A9e ha5e a social .orker an* he'she .ill fin* out financial help for you%A
In the KSA almost e5ery hospital .ill ha5e social .orker to *eal this kin* of pro)lems%
&5er talkati5e patient:
Some times the patient may talk en*lessly an* irrele5ant topics% So in those cases respon*
like this AExcuse me Mr% xy=? sorry to interrupt you% I kno. these things ha5e really )een )othering
you% Ho.e5er I nee* to focus completely on you >or on your present situation!%
Some patients .ill respon* normally )ut some patients .ill say AAre you interrupting meBA%
7onFt .orry they ha5e )een tol* to act like that% Say the same thing again an* say sorry once again%
Eeneral:
If you ha5e to say A I *onFt kno. A say AI *onFt kno. yetA%
Finally there are 2 popular mnemonics for history ta@ing)
(+,O. ''' >-ID&: is Associate* .ith Alcoholic Anonymous! especially if the chief complaint is a pain%
( < -ocation
+ < Intensity
,< Duantity
O < &rigin N *uration N fre;uency
. < :a*iation
' < Aggra5ating factors
' < Alle5iating or :elie5ing factors
' < Associate* pro)lems
The other mnemonic use* for the same purpose is 1O 2 , . 7 :1
Onset
2ro5ocation'2alliation
,uality
.a*iation
7ite
:emporal profile

The follo.ing is 5ery goo* for past history for all cases%
A2'3 4>97 FO77A
2re5ious episo*es of chief complaints%
'llergic history
3e*ical pro)lems in the past
4ospitali=ation >Trauma? surgeryI!
>rinary complaints
9astro intestinal pro)lems
7leep
Family History
O)stetric an* Eynecological History
7exual History
7ocial History
@ote: This history taking is for all cases an* in general% 9e ma*e an effort to explain ho. to elicit history in general
an* .hat nee*s to )e aske* for certain issues% $ou nee* not ask all these ;uestions for e5ery case% $ou ha5e to
prioriti=e .hat nee*s to )e aske* for particular case% That .ill come only .ith repeate* practice of cases that .e ha5e
gi5en%
<?amination
The aim here is to teach you ho. to examine a patient in the examination room%
Al.ays .ash your han*s .ith soap )efore the physical examination? *onHt .aste your time .hile .ashing
your han*s? 6ust turn your hea* to.ar*s patient .hile .ashing an* maintain con5ersation%
@e5er examine through the go.n? )ut at the same time try to *rape >co5er! the )o*y as much as you can%
Expose only the necessary part%
7onHt hesitate to examine heart in a female patient? lea5ing the )ra on? you can ask her to lift her )reast for
PMI > Point of maximum impulse! an* auscultation%
It is permissi)le to place stethoscope *o.n )et.een the )reasts to continue listening% 7onHt *o )reast
examination%
The *ictum is to inform patient the examination proce*ure )efore you examine%
Ex: Start like this:
$ou: G &k Mr% Samson no. I .oul* like to *o physical examination on you? for that I nee* to untie your go.n? is
that ok .ith youBJ
SP: G$es its okJ
$ou: GThank youJ
If the patient resists you? then you ha5e to explain the importance of examination to un*erstan* the *isease
process? something like this:
$ou: GMr% Samson I can un*erstan* your feelings )ut to clearly un*erstan* the *isease I
ha5e to *o this examination? it .ont take more than a minute *onHt .orry I am here to assist you% I
.ill tell you .hate5er I am going to *o%J
0
Some physical fin*ings can )e expresse* in SPHs face >fake*!% So )e careful an* al.ays o)ser5e SPHs face
.hile examining% Sometimes you may get a SP .ith hypertrophic tonsils as a case of sore throat%
Al.ays *o a focuse*? rele5ant examination% $ou .ont ha5e much time to *o e5erything% This .ill come only
.ith repeate* practice%
:espiratory Examination:
I*eally the patient shoul* )e sitting on the en* of an exam ta)le%
+nspection)
$ou: A@o. I .oul* like to examine your chest% Is that &M .ith youBA
&)ser5e the rate? rhythm? *epth? an* effort of )reathing%
-isten for o)5ious a)normal soun*s .ith )reathing such as .hee=es%
&)ser5e for retractions an* use of accessory muscles >sternoclei*omastoi*s? a)*ominals!%
&)ser5e the chest for asymmetry? *eformity? or increase* anterior<posterior >AP! *iameter%
2alpation)
$ou: A@o. I .oul* like to palpate your chest% -et me kno. if it hurts youA
-ook for tracheal *e5iation
I*entify any areas of ten*erness or *eformity )y palpating the ri)s an* sternum%
Assess expansion an* symmetry of the chest )y placing your han*s on the patientFs )ack? thum)s together at
the mi*line? an* ask them to )reathe *eeply%
Check for tactile 5ocal fremitus%
-ook for PMI >point of maximum impulse!%
2ercussion)
$ou: A@o. I am going to tap on your lungs to look for any flui* or excess airA
Percuss )oth anterior an* posterior chest from si*e to si*e then from top to )ottom
Interpretations:
If *ull< Pleural effusion or -o)ar pneumonia
Hyperresonant < Pneumothorax or Emphysema
'uscultation)
$ou: A@o. I .oul* like to listen to your lungs? can you take some ;uick nice *eep *eeps )reath for meA
Kse the *iaphragm of the stethoscope%
Auscultate anterior? posterior an* lateral si*es of the chest from si*e to si*e then from top to )ottom%
Tactile (remitus:
$ou: GCan you please say Aninety<nineA repeate*ly for meJ
Palpate .ith your lateral )or*er of palm%
Increase* tactile fremitus suggests consoli*ation of lung%
"
8ronchophony:
$ou: ACan you please say Aninety<nine? ninety<nineA repeate*ly for meBA
This time instea* of palpation *o auscultation% Auscultate se5eral symmetrical areas o5er each lung
The soun*s you hear shoul* )e muffle* an* in*istinct% -ou*er? clearer soun*s are calle* )ronchophony
>in*icates consoli*ation!
9hispering pectorilo;uy:
$ou: ACan you please .hisper Aninety<nine? ninety<nineA repeate*ly for meBA
Auscultate se5eral symmetrical areas o5er each lung%
In normal people you shoul* hear only faint soun*s or nothing at all% If you hear the soun*s clearly this is
referre* to as .hispering pectorilo;uy >in*icates consoli*ation!%
Special Points:
@e5er percuss or auscultate on scapula%
-et the Patient fully exhale or inhale )efore auscultating >shifting to! other area%
(or e5ery case of respiratory system *onHt forget to auscultate heart an* checking for PMI%
Car*io5ascular System:
Al.ays examine from patients right si*e%
Al.ays examine in " positions%
$ou: G&M Mr% Samson no. I .oul* like to examine your heart in sitting position then lying *o.n an* again in
sitting position%J
9hile the patient is in sitting position:
$ou: GI nee* to check your pulses%J
Check for pulses:
@ote .hether the pulse is regular or irregular
&)ser5e for caroti* pulse%
Auscultate for caroti* )ruits >a sign of arterial narro.ing an* risk of a stroke! for mi**le age* or el*erly
patients%
check for *epen*ent e*ema
7onHt measure )loo* pressure unless other.ise aske* >they usually gi5e the 8%P!%
Then ask the patient to lie *o.n
$ou: AI nee* to check your heart? coul* you please lie *o.n for meB IFll pull out the leg extension to make it a little
more comforta)le for youA
-ook for Cugular 3enous 7istention >C37!%
Position the patient supine .ith the hea* of the ta)le ele5ate* to "# *egrees%
Inspect for precor*ial mo5ement%
Then palpate for precor*ial acti5ity%
/
$ou may feel thrills or exaggerate* 5entricular impulses%
Palpate for the point of maximal impulse >PMI or apical pulse!%
@ote the location? si=e? an* ;uality of the impulse%
'uscultation)
$ou: G@o. I .oul* like listen to your heart soun*sJ
Position the patient supine .ith the hea* of the ta)le slightly ele5ate*%
:ecor* S? S0? >S"!? >S/!? as .ell as the gra*e an* configuration of any murmurs >At.o o5er sixA or A0'+A?
Apan systolicA or Acrescen*oA!%
-isten .ith the stethoscope *iaphragm at the right 0n* intercostal space near the sternum >aortic area!%
-isten at the left 0n* intercostal space near the sternum >pulmonary area!%
-isten at the left "r*? /th? an* ,th inter costal spaces near the sternum >tricuspi* area!%
-isten at the apex >mitral area!% Then ask the patient to turn to left si*e an* then listen mitral area%
:ecor* the rate? rhythm? an* any extra soun*s you hear%
Ask the patient to sit up again%
Again auscultate all / areas
Ask him to lean for.ar* an* listen at the )ase of heart%
Examination of the A)*omen:
The patient shoul* )e lying supine on the exam ta)le an* appropriately *rape*%
9atch the patientFs face for signs of *iscomfort *uring the examination%
Consi*er the inguinal'rectal examination in males an* pel5ic'rectal examination in females%
7onHt *o these examinations )ut tell the SP that you .ant to *o them later%
+nspection)
$ou: AI am looking at your )elly for any gross a)normalitiesA%
-ook for scars? s.ellings? an* hernias%
-ook for any 5isi)le peristalsis or pulsations%
@ote the a)*ominal contour >(lat? scaphoi*? or any a)*ominal *istention!%
'uscultation)
$ou: A @o. I .oul* like to listen to your )o.el soun*sA
It is 5ery important to auscultate prior to palpation
% -isten for )o.el soun*s%
0% -isten for )ruits o5er the renal arteries? iliac arteries? an* aorta%
2ercussion)
$ou: A@o. I .oul* like to tap on your )ellyA
Percuss in all four ;ua*rants%
Percuss the li5er span
% Percuss *o.n.ar* from the chest in the right mi*cla5icular line until you *etect the top e*ge
of li5er *ullness%
,
0% Percuss up.ar* from the a)*omen in the same line until you *etect the )ottom e*ge of li5er
*ullness%
"% The *istance )et.een the points is the li5er span%
Check for splenic *ullness
% Percuss the lo.est costal interspace in the left anterior axillary line% This area is normally
tympanic%
0% Ask the patient to take a *eep )reath an* percuss this area again% 7ullness in this area may
)e a sign of splenic enlargement%
2alpation)
$ou: A@o. I .oul* like to press on your )elly first lightly then *eeply% Please let me kno. if it hurtsA
Start .ith light >superficial! palpation% This is to look for any areas of ten*erness% -ook at the patientFs face
not on the a)*omen% The most sensiti5e in*icator of ten*erness is the patientFs facial Rexpression% Also look
for guar*ing >3oluntary or in5oluntary!%
Procee* to *eep palpation after light palpation%
Palpate the -i5er:
Place your fingers 6ust )elo. the right costal margin an* press firmly then ask the patient to take a *eep
)reath%
Palpate the aorta: If you suspect any aneurysms:
Palpate the spleen:
7pecial :ests)
:e)oun* Ten*erness:
This is a test for peritoneal irritation%
Tell the patient .hat you are a)out to *o% G@o. I .oul* like to press in an* release? please let me kno. if it
hurts .hen I press in or let go%J
Press *eeply on the a)*omen .ith your han* then after a moment? ;uickly release pressure%
If it hurts more .hen you release? the patient has re)oun* ten*erness%
Costo5erte)ral angle Ten*erness >C3A!:
C3A ten*erness is often associate* .ith renal *isease%
Tell the patient .hat you are a)out to *o% A@o. I .oul* like to gi5e fe. thumps on your )ack% Please let me
kno. if it hurts%A
% Ask the patient to sit up%
0% Kse the heel of your close* fist to strike the patient firmly o5er the costo5erte)ral angles%
"% Compare the left an* right si*es%
Shifting *ullness:
Can )e *one for flui* in the a)*omen% > Ksually not re;uire* for CSA!
+
Psoas sign:
This is a test for appen*icitis% (irst ask the Patient to turn on to the -t si*e% Then exten* the patients right leg%
This .ill cause stretching of the Psoas muscle an* .ill cause pain if it is irritate* )y inflame* appen*ix% SP
can act exactly like a real patient? so .atch his face%
&)turator sign:
This is also a test for appen*icitis%
% :aise the patientFs right leg .ith the knee flexe*%
0% :otate the leg internally at the hip%
"% Increase* a)*ominal pain in*icates a positi5e o)turator sign%
MurphyHs sign:
$ou: G@o. I .oul* like to press on your )elly? please take a )reath an* please let me kno. if it hurts%J
This is for suspecte* cholecystitis% Hook the finger of your right han* un*erneath the right costal margin at
the point .here the lateral )or*er of the rectus muscle intersects .ith the costal margin% Then ask the Patient
to take *eep )reath% If he complains of pain then the test is S5e%
@eurologic Examination:
Al.ays consi*er left to right symmetry%
&rgani=e your thinking into se5en categories:
% Mental Status
0% Cranial @er5es
"% Motor system
/% Coor*ination an* Eait
,% :eflexes
+% Sensory system
2% Special Tests
Mental Status:
-e5el of 5onsciousness: $ou: AHello Mr% S.anson? can you hear me If you hear me can you smile for meA%
&rientation in timeB place and person: $ou: A9here are .e no.B? .hat is the *ate to*ayB? can you please
tell me your full nameBA%
Assess Cudgment: $ou: A9hat .oul* you *o if you foun* a self a**resse* en5elop on the streetA%
$ou ha5e to test for memories of recent? remote an* registration%%
Test memory: :ecent remote registration% Simple .ay is AMr% S.anson? I am going to tell you " .ar*s% I
.ant you to remem)er them an* repeat them imme*iately% I .ill ask you to repeat the same .or*s after ,
minutes again% &k? Am I clearBA% Tell him APen? Car an* chairA% Ask again at the en* of mental status% (or
long term memory you can ask like A9hat happene* on Septem)er thBA%
'bstraction: $ou: ACan you please spell the .or* G9&:-7J )ack.ar*s for meBA
:hree ObDect 5ommand: AMr% S.anson? I am going to .rite a sentence here? please rea* the sentence an*
*o as it says? &kLA% $ou .rite AClose your eyesA on a paper% Some people *o serial F2Fs test )ut it is time
consuming? so .e *onHt a*5ise that% If you *o a)o5e + things that is more than sufficient for this exam%
Cranial ner5es:
2
&)ser5e for any gross a)normalities like
Ptosis >III!%
(acial *roop >or! asymmetry >3II!%
A)normal articulation of .or*s >3? 3II? P? PII!%
A)normal eye position >III? I3? 3I!%
A)normal or asymmetrical Pupils >II? III!%
&lfactory:
Ksually not teste* for this exam%
&ptic:
$ou: A@o. I nee* to examine your eyes? can you please count my fingersA%
Examine the optic fun*i%
Test 5isual acuity )y using SnellenFs chart or simply )y using your fingers%
Screen 5isual fiel*s )y confrontation%
Stan* t.o feet in front of the patient an* ha5e them look into your eyes% Hol* your han*s a)out one foot
a.ay from the patientFs ears? an* .iggle a finger on one han*% Ask the patient to in*icate .hich si*e they see
the finger mo5e% :epeat t.o or three times to test )oth temporal fiel*s% If an a)normality is suspecte*? test
the four ;ua*rants of each eye .hile co5ering the other .ith the patients han*%
Test pupillary reactions to -ight%
% 7im the room lights as necessary%
0% Ask the patient to look into the *istance%
"% Shine a )right light o)li;uely into each pupil in turn%
/% -ook for )oth the *irect >same eye! an* consensual >other eye! reactions%
,% :ecor* pupil si=e an* any asymmetry or irregularity%
&culomotor:
&)ser5e for ptosis%
Test extra ocular mo5ements%
Ask the patient to follo. your finger .ith their eyes .ithout mo5ing their hea*%
Check ga=e in the six car*inal *irections using a cross or AHA pattern%
Pause *uring up.ar* an* lateral ga=e to check for nystagmus%
Check con5ergence )y mo5ing your finger to.ar* the )ri*ge of the patientFs nose%
Test pupillary reactions to light%
Trochlear:
Test extra ocular mo5ements >In.ar* an* *o.n.ar* mo5ement!%
Trigeminal:
Test motor strength%
Ask the patient to clench his'her teeth%
4
Palpate the temporal an* masseter muscles as they *o this%
Test the " *i5isions for pain sensation%
Explain .hat you inten* to *o%
Kse a suita)le sharp o)6ect to test the forehea*? cheeks? an* 6a. on )oth si*es%
Su)stitute a )lunt o)6ect occasionally an* ask the patient to report AsharpA or A*ull%A
Test the corneal reflex >Ksually not re;uire* for this exam!%
A)*ucens:
Test extra ocular mo5ements >-ateral mo5ement!%
(acial:
&)ser5e for any facial *roop%
Ask patient to *o the follo.ing? note any lag? .eakness? or asymmetry:
:aise eye)ro.s >ACan you please raise your eye)ro.s for meBA!%
Close )oth eyes to resistance >AI .ill try to open your eyes? *onHt let me open%A!%
Smile > ACan you please smile for meBA!%
(ro.n >ACan you please fro.n for meBA!%
Sho. teeth >ACan you please sho. your teeth for meBA!%
Test the Fcorneal reflexF >Ksually not re;uire* for this examination!%
Acoustic:
Screen hearing
Test the hearing )y making simple noise .ith fingers%
If a)normal? then *o 9e)er an* :inne tests%
Test for laterali=ation >9e)er!
Kse a ,0 H= tuning fork%
Place the )ase of the 5i)rating tuning fork firmly on top of the patientFs hea*%
Ask the patient .here the soun* appears to )e coming from >normally in the mi*line!%
Compare air an* )one con*uction >:inne!
Kse a ,0 H= tuning fork%
Place the )ase of the 5i)rating tuning fork against the mastoi* )one )ehin* the ear%
9hen the patient no longer hears the soun*? hol* the en* of the fork near the patientFs ear
>air con*uction is normally greater than )one con*uction!%
3esti)ular function is not normally teste*%
Elossopharyngeal: Ksually not re;uire* for this examination%
3agus:
1
-isten to the patientFs 5oice? is it hoarse or nasalB
Ask the patient to s.allo.%
Ask the patient to say AAhA
9atch the mo5ements of the soft palate an* the pharynx%
Test Fgag reflexF >Knconscious'Kncooperati5e Patient! >Ksually not re;uire* for this examination!%
Accessory:
(rom )ehin*? look for atrophy or asymmetry of the trape=ius muscles%
Ask the patient to shrug his shoul*ers against resistance >ACan you please shrug your shoul*ers for meBA!%
Ask the patient to turn his hea* against resistance% 9atch an* palpate the sternomastoi* muscle on the
opposite si*e >ACan you please turn your hea* against my hea*BA!%
Hypoglossal:
-isten to the articulation of the patientFs .or*s%
Ask patient to stick out the tongue then ask him to mo5e tongue from si*e to si*e >ACan you please stick out
your tongueB an* mo5e it si*e to si*eBA!%
3otor)
&)ser5ation:
In5oluntary mo5ements
Muscle symmetry an* atrophy% Al.ays compare )oth >right an* left! si*es% Check is there any *ifference
)et.een proximal an* *istal muscle groups%
Eait
Muscle tone:
$ou: A@o. I .oul* like to check your muscle tone? please relax your muscles% &MA
(lex an* exten* the patientFs fingers? .rist? an* el)o.%
(lex an* exten* patientFs ankle an* knee%
There is normally a small? continuous resistance to passi5e mo5ement%
&)ser5e for *ecrease* >flacci*! or increase* >rigi*'spastic! tone%
Muscle Strength:
$ou: A@o. I .oul* like to check your muscle strength'po.erA%
Test strength )y ha5ing the patient mo5e against your resistance%
Al.ays compare one si*e to the other%
Era*e strength on a scale from # to , Aout of fi5eA:
#', @o muscle mo5ement at all
', Cust flicker of mo5ement%
0',
Mo5ement at the 6oint? )ut not against gra5ity

"',
Mo5ement against gra5ity? )ut not against
a**e* resistance
0#
/',
Mo5ement against resistance? )ut less than
normal
,', @ormal strength
Test the follo.ing:
Spine >G@o. I .oul* like to check the flexi)ility of your spine? please lean o5er at the .aist? an* try to touch
your toesJ!
Kpper lim):
(lexion at the el)o. >Gcan you please pull inJ!%
Extension at the el)o. >Gcan you please push outJ!%
(lexion an* Extension at the .rist >Gcan you please pull up an* push *o.nJ!%
S;uee=e t.o of your fingers as har* as possi)le >Acan you please s;uee=e my finger as tightly as you canJ!%
(inger a)*uction >ulnar ner5e! >Gcan you please sprea* out your fingersJ!%
&pposition of the thum) >me*ian ner5e!%
-o.er lim):
(lexion at the hip >iliopsoas!: >Gcan you please pull inJ!
A**uction at the hips >a**uctors!: >Gcan you get your thighs closer to each otherJ!
A)*uction at the hips >gluteus me*ius an* minimus!: >Gcan you please mo5e out your thighs one from the
otherJ!
Extension at the hips >gluteus maximus!: >Gcan you please push out your thighsJ!
Extension at the knee >;ua*riceps!: >Gcan you please kick outJ!
(lexion at the knee >hamstrings!: >Gcan you please pull inJ!
7orsiflexion at the ankle: >Gcan you please pull inJ!
Plantar flexion >S!: >Gcan you please push *o.nJ!
Coor*ination an* Eait:
Cere)ellar (unction Tests:
Coor*ination an* gait >G@o. I .oul* like to check your )alance an* mo5ementsJ!
:api* alternating mo5ements i%e% ask him to *o rapi* supination an* pronation of han*s%
Point<to<Point Mo5ements: GCan you please touch your finger to my finger an* then to your noseJ% Ask the
patient to touch your in*ex finger an* their nose alternately se5eral times% Mo5e your finger a)out as the
patient performs this task%
Ask the patient to place one heel on the opposite knee an* run it *o.n the shin to the )ig toe% :epeat .ith the
patientFs eyes close*% If you *o the a)o5e test you *onFt nee* to *o this one%
:om)ergFsH test:
$ou: GCan you please stan* up for me an* get your feet together% Can you please close your eyes? *onHt .orry I .ill
assist you if you fallJ%
8e prepare* to catch the patient if they are unsta)le%
Ask the patient to stan* .ith the feet together an* eyes close* for ,<# secon*s .ithout support%
The test is sai* to )e positi5e if the patient )ecomes unsta)le >its a test for sensory ataxia not for cere)ellar
ataxia!%
0
Eait:
$ou: GCan you please .alk fe. steps for meJ%
Ask the patient to rise from a sitting position? .alk across the room? turn an* come )ack > Eet up an* go test!
Ask the patient to .alk in a straight line: GCan you please .alk in a straight line for meJ
.efle?es)
G Miss CSA? no. I .oul* like to check your 6erks% (irst? let me )egin .ith your arms% Then? let me check your legs%
Please relax your musclesA
7eep Ten*on :eflexes:
The patient must )e relaxe* an* positione* properly%
:eflexes can )e reinforce* )y asking the patient to perform isometric contraction of other muscles >clenche*
teeth!: >GCan you please clench your teeth for a .hileJ!%
:eflexes shoul* )e gra*e* on a # to / AplusA scale:
# A)sent
S Hypoacti5e >*iminishe*!
0S A@ormalA
"S
Exaggerate* .ithout
clonus
/S Exaggerate* .ith clonus
8iceps >C,? C+!%
Triceps >C+? C2!%
8rachiora*ialis >C,? C+!%
A)*ominal >T4? T1? T#? T? T0!%
Mnee >-0? -"? -/!%
Ankle >S? S0!%
Clonus:
If the reflexes are exaggerate*? test for ankle clonus%
Plantar response >8a)inski!: Stroke .ith a )lunt o)6ect along the lateral )or*er of the feet% Extension of the
)ig toe .ith fanning of fingers is a)normal% This is referre* to as a positi5e 8a)inski%
7ensory)
$ou: A@o. I .oul* like to check your sensory perception in *ifferent areas of the )o*yA%
Eeneral:
Explain each test )efore you *o it%
PatientFs eyes shoul* )e close* *uring the testing%
Compare symmetrical areas on the right an* left%
Also compare *istal 5erses proximal%
3i)ration:
00
Kse a lo.<pitche* tuning fork >04H=!%
Test .ith a non<5i)rating tuning fork first to ensure that the patient is respon*ing to the correct stimulus%
Place the stem of the fork o5er the *istal interphalangeal 6oint of the patientFs in*ex fingers an* )ig toes%
Ask the patient to tell you if he feels the 5i)rations%
If 5i)ration sense is impaire* procee* proximally
% Kpper lim): (rom .rists? el)o.s etc:
0% -o.er lim): (rom me*ial malleoli? patella? anterior superior iliac spine%
Position Sense:
Erasp the patientFs )ig toe an* sho. the patient AupA an* A*o.n%A
9ith the patientFs eyes close* ask the patient to i*entify the *irection you mo5e the toe%
If position sense is impaire* mo5e proximally to test other 6oints%
Test the fingers in a similar fashion%
If 5i)ration? position sense? an* su)6ecti5e light touch are normal in the fingers an* toes you may assume the
rest of this exam .ill )e normal%
Pain:
$ou: GPlease un*erstan* this is sharp an* this is *ull? no. close your eyes an* let me kno. .hich is .hatJ
Kse a suita)le o)6ects to test AsharpA an* A*ullA sensations%
Test the follo.ing areas:
Shoul*ers >C/!%
Inner an* outer aspects of the forearms >C+ an* T!%
Thum)s an* little fingers >C+ an* C4!%
(ront of )oth thighs >-0!%
Me*ial an* lateral aspect of )oth cal5es >-/ an* -,!%
-ittle toes >S!%
Temperature:
&ften omitte* if pain sensation is normal%
-ight touch:
Kse a fine .isp of cotton or your fingers to touch the skin lightly%
Ask the patient to respon* .hene5er a touch is felt%
Test the follo.ing areas:
Shoul*ers >C/!
Inner an* outer aspects of the forearms >C+ an* T!
Thum)s an* little fingers >C+ an* C4!
(ront of )oth thighs >-0!
Me*ial an* lateral aspect of )oth cal5es >-/ an* -,!
-ittle toes >S!
7iscrimination:
0"
Since these tests are *epen*ent on touch an* position sense? they cannot )e performe* .hen the tests a)o5e
are clearly a)normal%
T.o point *iscrimination < Ksing 0 pins >pointe* e*ges! touch finger pa* in 0 places simultaneously%
Alternate .ith a one point touch% The *istance )et.een the 0 points shoul* )e T, mm on the finger pa*s%
Special tests:
MerningHs Sign: Here the patient lies on )ack% (lex )oth knee an* hip then try to exten* the knee only% In
meningitis? patient .ill complain of pain or resistance to knee extension%
8ru*=inskiFs Sign: 9hen you flex the neck? there may )e a flexion of the patient hips an* knees% This is also
seen in meningitis patients%
@eck stiffness: Ha5e the patient lie on )ack? place your han* )ehin* the patients neck an* flex it until the
chin touches the sternum% In meningitis he .ill complains of neck pain an* you .ill notice resistance to
motion%
Examination of the Hea* an* @eck:
Hea*:
-ook for scars? lumps? rashes? hair loss? or other lesions
-ook for facial asymmetry? in5oluntary mo5ements? or e*ema%
Palpate to i*entify any areas of ten*erness or *eformity%
Eyes:
A@o. I nee* to examine your eyesA%
Test the 5isual acuity )y using SnellenHs chart%
Inspection:
Ask the patient to look up an* pull *o.n )oth lo.er eyeli*s to inspect the con6uncti5a an*
sclera% @ote any *iscoloration? re*ness? *ischarge? or lesions% @ote any *eformity'lesions of the iris
an* cornea%
Extra ocular muscles:
$ou: GI .ill shine this light on your eyes? please look at some o)6ectsJ%
Corneal :eflections:
Shine a light from *irectly in front of the patient%
The corneal reflections shoul* )e centere* o5er the pupils%
Asymmetry suggests extra ocular muscle pathology%
Test for extra ocular mo5ements
Test 5isual fiel*s
-ook pupillary reactions to light
&phthalmoscopic exam:
7arken the room as much as possi)le%
A*6ust the ophthalmoscope so that the light is no )righter than necessary
0/
Kse your left han* an* left eye to examine the patientFs left eye% Kse your right han* an*
right eye to examine the patientFs right eye%
Ask the patient to look at a point on the .all%
Examine retina an* fun*us an* note any a)normalities%
Ears:
Inspect the auricles an* mo5e them aroun* gently% Ask the patient if this is painful%
Palpate the mastoi* process for ten*erness%
Hol* the otoscope then pull the ear up.ar*s an* )ack.ar*s to straighten the canal%
Insert the otoscope% Inspect the ear canal an* mi**le ear structures an* note any re*ness? *rainage? or
*eformity%
@ose:
Inspect the nose
Tilt the patientFs hea* )ack slightly%
Insert the otoscope into the nostrilO try to a5oi* contact .ith the septum% Inspect the 5isi)le nasal structures
an* note any s.elling? re*ness? *rainage? or *eformity%
Throat:
$ou: GI nee* to look insi*e your mouth for any ulcers or *ental pro)lemsJ%
Ask the patient to open their mouth%
@ote any ulcers? .hite patches >leucoplakia!? or other lesions:
Inspect the posterior oropharynx )y *epressing the tongue .ith tongue *epressor an* asking the patient to
say AAh%A @ote any tonsillar enlargement? re*ness? or *ischarge%
@eck:
Inspect the neck for asymmetry? scars? or other lesions%
Palpate the neck to *etect areas of ten*erness? *eformity? or masses%
-ymph @o*es:
$ou: G@o. I .oul* like to check for any s.ollen glan*s? let me press on this areaJ
Systematically palpate the 5arious lymph no*e groups%
Check superficial cer5ical? supra cla5icular? an* the *eep cer5ical lymph no*es% The *eep cer5ical chain of
lymph no*es lies )elo. the sternomastoi* an* cannot )e palpate* .ithout getting un*erneath the muscle%
Inform the patient that this proce*ure .ill cause some *iscomfort% Hook your fingers un*er the e*ge of the
sternomastoi* muscle% Ask the patient to )en* their neck to.ar* the si*e you are examining% Mo5e the
muscle )ack.ar* an* palpate for the *eep no*es un*erneath%
@ote the si=e an* location of any palpa)le no*es an* .hether they .ere soft or har*? non<ten*er or ten*er?
an* mo)ile or fixe*%
Thyroi* glan*:
$ou: A-et me check you thyroi*? I am going to press 5ery gently gently on this areaA
Inspect the neck looking for the thyroi* glan*%
0,
@ote the si=e? symmetry? an* position of the lo)es? as .ell as the presence of any no*ules% The normal glan*
is often not palpa)le%
7pecial :ests)
(acial ten*erness:
$ou: G@o. I .oul* like to check your sinuses I am going to press on your forehea* an* sinuses? please let me kno.
if it hurtsJ%
Ask the patient to tell you if these maneu5ers cause excessi5e *iscomfort or pain%
Press up.ar* un*er )oth eye)ro.s .ith your thum)s%
Press up.ar* un*er )oth maxillas .ith your thum)s%
Excessi5e *iscomfort on one si*e or significant pain suggests sinusitis%
Sinus transillumination:
7arken the room as much as possi)le%
Place a )right point light source on the maxilla%
Ask the patient to open his mouth an* look for an orange glo. on the har* palate%
A *ecrease* or a)sent glo. suggests that the sinus is fille* .ith something other than air%
Temporoman*i)ular 6oint:
$ou: G@o. I nee* to examine your 6a. 6ointJ%
Place the tips of your in*ex fingers *irectly in front of the tragus of each ear then ask the patient to open an*
close their mouth%
@ote any *ecrease* range of motion? ten*erness? or s.elling%
Musculoskeletal System:
Inspection:
Inspect the area%
Al.ays compare .ith the opposite area%
Al.ays compare other 6oints for any signs of a)normality%
Palpation:
Palpate the area for .armth? an* look for any s.elling%
Palpate for ten*erness an* crepitus%
Check range of motion%
Al.ays check the neurological status >motor? sensory? reflexes%! an* 5ascular status of that area%
Special situations:
Mnee:
Al.ays *o 7ra.ers test an* Mc%MurrayHs test if patient has a H'& trauma to the knee%
Click here for %rawers test.
Click here for 3c.3urrayEs test .
0+
Shoul*ers:
:ange of motion is crucialO ask him to touch the opposite shoul*er%
9rist:
Check neurological >*ermatomes! status%
Spine:
Check the flexi)ility? gait an* reflexes
-eg:
HomanFs sign < this is usually *one for suspecte* *eep 5ein throm)osis% (orceful *orsiflexion
of the foot .ill cause pain the calf%
5losing the <ncounter
AAll right? Mr% xy=? thank you so much for your kin* cooperation% @o. IF* like to sit *o.n an* talk o5er .hat I think
so far% (irst let me summari=eA >transition!%
$ou 6ust tol* me that RR an* RR% Also? you sai* that RR an* RR? Is that rightB
Accor*ing to the information I got from you an* )y examination? I am consi*ering a couple of possi)ilities%
It may )e RR >your pro)a)le *iagnosis! or possi)ly RR>*ifferential *iagnosis!%
I nee* to run some tests in or*er to fin* out exactly .hat it is%
As soon as I get the results? let us meet again to go o5er e5erything% At that time? IFll explain the *etails an*
.e .ill talk a)out your options for treatmentB 7oes this soun* &MB
If it is a psychiatric case? like *epression? grief? anxiety? or *ementia? ask this ;uestion:
Miss xy=? .oul* you )e .illing to talk to a counselor or go to a support groupB
If Mr%'Miss xy= smokes? *rinks alcohol? eats fatty foo*? *oes not exercise? uses recreational *rugs? has
multiple sexual partners? *oes not use con*oms? etc? gi5e follo.ing suggestions:
Mr%'Miss xy=? I ha5e notice* that youRR>a**ress the pro)lems!? are you .illing to ;uitB% If you nee* any
more help from me? 6ust let me kno.% IFll )e gla* to help you%
Miss xy=? *o you ha5e any concerns or ;uestions youF* like to ask )efore I goB
9ell then? I am 5ery grateful that I coul* )e a)le to .ork .ith you% I .ill *o my le5el )est to make you feel
)etter% ok
Thanks for your cooperation? ha5e a goo* *ay% 8ye for no.? take care%

Friting patient notes using abbre"iations
9e ha5e use* short cuts here so that you can follo. these short cut language to sa5e your time
02
4istory)
CC >Chief Complaints!:
9rite the chief complaint%
HPI >History of Present Illness!:
9rite the present history .ith other positi5e an* negati5e symptoms%
PMH >Past Me*ical History!:
$ou can follo. this acronym so that you .ont miss any point > practically in the exam you .ill still miss
some points so practice .ell!
PAM HKES (&SS
P< @o similar Pro)lems in the past
A<@MA > @o Mno.n Allergies!
M<Me*ical Pro)lems
H< Hospitali=ation
K< Krinary Pro)lems
E< EI Pro)lems
S< Sleep
(H >(amily History!:
(amily History
&)g'Eyn:
Sex H:
SH >Social History!
2hysical e?amination
(irst .rite 5ital signs
Then focus on main systemic examination
-astly .rite a)out re5ie. of other systems
Tips:
Al.ays .rite 5ital signs first
Ei5e a )rief comment a)out Pts general appearance
Then .rite a)normal fin*ings
Then rele5ant positi5e an* negati5e fin*ings
+n"estigations
Al.ays .rite most specific tests first
-ist the tests in or*er of priority
9rite all the relate* tests in a single line Ex:: C8C? ES:%%%
04
7o not .rite referrals? consultations
7o not .rite :x
$ou ha5e to mention a)out )reast? renal? pel5ic? genital examinations if nee*e* to )e *one for respecti5e
cases%
%ocumentation of normal respiratory e?amination)
8reathing:
@ormal rate
:hythm
Trachea central
@o accessory muscles are acting
-ungs are clear to percussion
&n auscultation:
@ormal 5esicular )reath soun*s
@o .hee=es'rales'ru)s
T3( is 9@- >9ith in @ormal -imits!
%ocumentation of normal cardio"ascular system e?amination)
Inspection:
@o 5isi)le scars? hea5es
Palpation:
PMI non<*isplace*'no pe*al e*ema
@o thrills
@o hea5es%
Auscultation:
S' S0 hear*
@o S" 'S/
@o murmurs'gallops'ru)s%
-ungs are clear
@o a**itional soun*s
%ocumentation of normal abdominal e?amination)
Inspection:
@o scars
@o s.ellings
@o 5isi)le peristalsis
@o 5isi)le pulsations
Auscultation:
8o.el soun*s are hear*
01
@o )ruit
Palpation:
A)*omen is soft? non ten*er
@o masses felt
@o organomegaly
@o C3A ten*erness
@o re)oun* ten*erness
Percussion:
Tympanic in all / ;ua*rants
-i5er span is normal
@o free flui*%
%ocumentation of e?amination of spine)
Inspection:
@o o)5ious a)normalities
Palpation:
@o prominent spinous process
@o paraspinal ten*erness
:ange of motion is 9@- >.ith in normal limits!%
Eait:
9@-
:eflexes:
0 S
%ocumentation of normal central ner"ous system e?amination)
Mental status:
Pt is alert
&riente* in time? place? person? an* intact memory%
Cranial ner5es:
II to PII intact
Motor:
,', in all muscle groups
7T::
"#
0 S? symmetric
Sensations are intact to sharp an* *ull
Cere)ellar:
@o positi5e signs
8a)inski negati5e
@o meningeal signs%
%ocumentation of normal 4<<6: <?amination
Hea*:
Atraumatic
@ormocephalic%
Eyes:
3isual acuity an* 5isual fiel*s 9@-
E&M<intact
PE:-A >Pupils E;ual an* :eacting to -ight!
(un*us is normal
Ears:
@o ten*erness
@o ear canal an* tympanic mem)rane a)normalities
@ose:
@o external a)normalities
Tur)inates are not congeste*
@o masses seen
Throat:
@o ulcers
@o erythema or exu*ates
@o patches
Tonsils are @
@o *ental or gum a)normalities
@eck:
Supple
Thyroi* is not palpa)le
@o palpa)le lymph no*es%
+n"estigations
These are the common in5estigations that you shoul* keep in min* .hile .riting Pt notes%
4<<6:)
"
% P<ray ? CT? M:I of hea*
0% Eye< SnellenHs chart? 3isual acuity
"% Ear< Complete au*iometry an* tympanometry? Culture'Sensiti5ity for any *ischarge
/% :outine C8C .ith *iff? ES:
567)
% :outine C8C .ith *iff? ES:
0% P<ray? CT? M:I
"% -um)ar puncture
/% Caroti* 7oppler stu*y
,% EEE
+% Electromyography an* @er5e con*uction stu*ies%
2% Echocar*iogram for suspecte* em)olic phenomena%
3usculos@eletal)
% :outine C8C .ith *iff? ES:
0% P<ray
"% Coint aspiration for culture' sensiti5e? cytology? crystals
/% :heumatic factor? H-A<802?
,% Serum uric aci* le5els
+% Antinuclear anti)o*ies? anti *s7@A
2% Muscle )iopsy
587)
% EME an* echocar*iogram
0% Car*iac en=ymes >CPM<M8? Troponin? -7H!
"% Chest P<ray
/% -ipi* profile
,% Thyroi* screen
"0
+% Serum electrolytes
.espiratory)
% :outine C8C .ith *iff? ES:
0% Chest P<ray
"% Sputum stu*ies >culture'sensiti5ity? gram stain? A(8!
/% Pulmonary function tests an* spirometry
,% PP7
+% A8E an* pulse oximetry
'bdominal)
% :outine C8C .ith *iff? ES:
0% A)*ominal P<ray
"% Kltrasoun* of a)*omen
/% -(Ts
,% CT a)*omen'pel5is
+% Kpper EI series<8arium s.allo.? en*oscopy? E:CP
2% -o.er EI series< enema? Colonoscopy
4% Test for fecal occult )loo*'rectal examination
1% Pancreatic en=ymes >amylase? lipase!
#% :enal function tests
<ndocrine)
% :outine C8C .ith *iff? ES:
0% 8loo* sugar
"% Serum electrolytes
/% Serum calcium
,% Thyroi* screen T/'T"'TSH
+% 0/hr urinary catecholamines an* meta)olites
""
2% Krine for ketones an* sugar%
2sychiatry)
% C8C an* ES:
0% CT an* M:I of )rain
"% Thyroi* screen
/% Electrolytes
,% Krine analysis
+% 7rug screen ' HI3
5ommunication s@ills
Things you nee* to )ear in min* through out your encounter .ith the SPHs: >A ;uick glance!
Al.ays @noc@ the *oor )efore entering the room%
&nce you enter the room first introduce yourself )y name an* greet the SP .armly%
Al.ays use 7.2Gs name to a**ress him'her%
Maintain goo* eye contact% This *emonstrates your self<confi*ence an* creates a sense of trust an*
cre*i)ility% (or example *uring a)*ominal palpation? o)ser5e the patientHs face for any signs of pain or
*iscomfort% 7uring most of the encounter? you shoul* maintain eye contact%
8efore you ask any specific ;uestion al.ays ask fe. open;ended ;uestions% This is the )est .ay to elicit
history from the patient% $ou may ask "</ open<en*e* ;uestions on the .hole for each case% $ou can start
off .ith your case like this: G 9hat cause* you to come in to*ayA G Coul* you please tell me more a)out
.hatFs going on%J An* so on%
Ask non leading ;uestions%
Ask only one -uestion at a time% 7onot ask too many ;uestions at a time% Ask a ;uestion? pause an* .ait for
the ans.er then procee* to the next one% Example: G 7oes anyone in the family ha5e high )loo* pressureI
>pause an* .ait for the ans.er!% I*ia)etesI>pause an* .ait for the ans.er!%
Al.ays pay attention an* listen to SPHs patiently .ith out interrupting them in )et.een%
Try to ac@nowledge their emotions%
Kse laymanGs language% Try not to use me*ical terms like hypertension for high )loo* pressure%
Kse appropriate transition sentences%
Fash your han*s )efore starting physical examination%
:ell the SP .hat you are going to *o >one at a time? not the .hole proce*ure as they shoul* for one of the
case in CSA cassette!%
%o not examine through the go.n%
Take 7.2Gs permission )efore untying the go.n% Help him'her un*o the )uttons%%
Kse appropriate draping techni;ues% The rule of thum) is: AAs little of the )o*y shoul* )e expose* as
necessary for a set of maneu5ers to )e performe*% (or instance? to auscultate the heart or lungs? you shoul*
@&T raise the go.n up from the .aist? exposing the entire torso% :ather? she'he shoul* lo.er the go.n from
the top? exposing only the upper chest an* shoul*ersA%
&ffer help to SPHs *uring examination% >&n an* off the ta)le!%
6e"er repeat painful maneu5ers an* al.ays apologi=e imme*iately for the slightest pain cause*%
7ummari&e the history an* e?plain physical fin*ings%
"/
Express empathyO make appropriate reassurances >do not gi"e false reassurance!% $ou can con5ey empathy
in a num)er of .ays? inclu*ing atten*ing to the patientFs physical comfort% $ou shoul* exten* the leg rest
.hen the patient lies )ack an* push it )ack in .hen the S%P sits )ack up% If the patient is in pain? ask if there
is anything you can *o to help to feel more comforta)le%
Ask .hether he'she has any concerns/ -uestions >7o you any ;uestions or concernsB!% This is the most
important thing that you shoul* ne5er forget to ask%
2sychiatry 4istory :a@ing
Ask .hat )rings the patient in to*ay
Ask .hat the patient thinks the pro)lem coul* )e *ue to >This .oul* gi5e you a concrete ans.er if the
psychiatric manifestations .ere *ue to reacti5e causes% 8e prepare* for a negati5e ans.er in most of the
cases%!
Ask if the patient has any)o*y to talk to .hen he is in *istress >Support systems!
Ask if the patient has ha* any unusually traumatic episo*es *uring the past fe. months or in the remote past
>PTS7!
Ask a)out any changes in appetite
Ask a)out any changes in sleep patterns >Pro)lem falling asleep? Pro)lem maintaining sleep? Pro)lem .ith
early morning a.akening% Ask also a)out nightmares an* *reams
Ask a)out any .eight loss'gain
Ask a)out the *aily routine of the patient% >Coul* you *escri)e to me a typical *ay in your life at the
moment!
Ask a)out the patientHs interests an* ho))ies an* ask if they ga5e her the same kin* of pleasure that they
ga5e her earlier%
Ask a)out the moo* most of the *ay
Ask a)out the *uration of these symptoms
Ask if the patient is fre;uently forgetting things or feels that she is losing her memory
Ask the patient a)out her general attitu*e to.ar*s life% >7o you ten* to look at things In a positi5e frame of
min* or in a negati5e frame of min*!
Ask a)out the patients sexual life
Ask if the patient has e5er consi*ere* en*ing her life
Ask if the patient has any plans regar*ing ho. to en* her life
Ask if there are pills or guns at home
Ask a)out family life an* the affinity of the patient to.ar*s her family mem)ers
Ask a)out any excessi5e coffee intake
Ask a)out *rugs? alcohol? recreational *rugs% If yes then ask a)out the last time that the patient ha* these
*rugs% The psychiatric manifestation may )e *ue to a .ith*ra.al syn*rome%
Ask a)out any *elusions or hallucinations% >7o you listen an* see .hat others canHt% Ha5e you felt 5oices
talking to you only an* no)o*y else aroun* you!
Ask a)out heat or col* intolerance an* other thyroi* manifestations%
7o an Mini Mental Status Examination%% >Please look up the C@S history taking for the MMSE !
Ask if the patient reali=es that she has a pro)lem
Ask if the patient is .illing to get help
5hallenging psychiatric situations)
",
The silent patient : If the patient is not ans.ering you? stay silent for a minuteO esta)lish eye contact% Put a
han* on the shoul*er an* say GI kno. that this is 5ery har* for you% 9ill you share it .ith meB I am here to
help you out% 9e can *o it together%J
The o5er talkati5e patient: If you are not a)le to get a .or* e*ge.ays? stop the patient an* firmly say thatO I
kno. that all these things )other you )ut my no priority right no. is you% So lets talk a)out you for no.%
7ample documentation of a psychiatric patient note
Patient *ishe5ele*
Speech: scant? goal *irecte*
Moo*: *ysthymic
Affect: moo* congruent
Memory: :ecent an* remote: Intact
7elusions an* hallucinations: none
MMSE results
Concentration:
Suici*al intent
A)straction an* Cu*gment
Insight
7uration of symptoms
Precipitating factors
Thyroi*: not palpa)le
Fhy do students fail0 :his is an e"ergreen -uestionB which remains unanswered. <"ery student who appears
for the 57' is capable of passing. :hen why do certain students pass and certain fail0
8ase* on my o)ser5ations I ;uote* certain reasons as to .hy stu*ents fail% 8y noting these reasons you can
potentially a5oi* pitfalls that you encounter in CSA%
The )est .ay for success is time* practice of simulate* cases on real people% Practice? practice? an*
practice%%%
Most of the can*i*ates .ho appear for CSA mess it up )y )ecoming ner5ous an* anxious% 7onFt *o that%
Maintain your cool an* composure%
7onFt )e o5er confi*ent% Some of my frien*s .ho got a)o5e 1# in )oth the steps flunke* the CSA% They
thought that they coul* easily clear the CSA an* they *i* not *o the preliminary preparation re;uire* for the
CSA% That *oesnFt mean that CSA is tough% If you think you speak English .ell an* you .ill pass )ecause
you are fluent? think again% This exam not only tests your communication skills? )ut also ho. you collect an*
*igest info to reach a *iagnosis? also tests your a)ilities in .riting%
If you fail? *onFt feel *epresse*% It 6ust means you nee* to )rush up a little% ItFs not the en* of the .orl*% So
*onFt gi5e up? 6ust take it again an* )e more prepare* the next time aroun*%
If you are poor in English try to impro5e it% $ou *onFt ha5e to speak like a @ati5e American )ut you shoul*
)e a)le to communicate clearly .ith the patient%
(irst rea* the CSA orientation manual 5ery .ell? the exam is 5ery similar to that%
This exam is a 5ery )asic assessment of your *ata gathering a)ility >History Taking!? the Communication
an* Interpersonal Skills assessment%
$ou nee* to kno. ho. to take a highly rele5ant an* focuse* history an* P'E in , min%
9hen they say focuse*? they mean focuse*% If you o5er *o the history taking your communications part .ill
suffer%
Knfortunately up to 4#U of people are failing in *ata gathering? so *onFt neglect that part%
The .ay one intro*uces oneself to the patient is 5ery important% All of the follo.ing statements appear goo*
)ut they are not << Hi? My name is 7r%<<<<<<% Ho. are you *oing to*ayB 9hat )rings you hereB
"+
% The main fault .ith the a)o5e statements is that you ne5er a**ress the patient )y the name%
0% The correct .ay to intro*uce your self is? Hello Mr%<<< >patients last name! IFm 7r%<<<>your last
name!% 9hat )rings you here to*ayB
"% Al.ays a**ress the patient )y name an* ne5er intro*uce yourself .ithout a**ressing the patient%
Meep as close as possi)le to the CC an* relate* history% 9hen asking the family history or past history? use
)roa* open ;uestions? if there is any thing significant? they .ill tell you% In<fact they .ill )e .aiting for you
to ask that ;uestion%
Timing is 5ery important% Try to )e half .ay through the P'E .hen they announce that , mts are remaining%
Expect e5ery *ay common cases only%
:emem)er to knock on the *oor? shake his han*? an* sho. him your teethLLL <<< Smile%
$ou may )e ner5ous .ith the first S%P% @e5er panic%
The first S%P may )e the har*est )ecause you *onFt kno. .hat to expect )ut later you get the hang of it try to
pace your self .ell? *onFt lea5e the room early? *onFt rush the patient%
Take a goo* history an* make a mental note of the ;uestions you must ask for a particular symptom%
Most patients are spontaneous up to a point? an* then start asking them specific ;uestions to further explore
the symptoms%
Stu*y the *ifferentials of common symptoms? 0 to " of the most common in America .ill *o% $ou canFt rule
out more in 2<4 mts time%
Prepare *ifferentials on common symptoms not *iseases%
Al.ays )e polite an* smile? e5en if the patient is acting *ifficult%
Kse common sense? an* try to communicate effecti5ely% Eetting the message across is more important than
talking en*lessly%
If a patient is in pain? *onFt imme*iately start interrogating him like an (8I agent% 8ut ask him .hether he is
in pain an* if he can ans.er some ;uestions to )etter un*erstan* the cause of his pain%
7o a focuse* history an* al.ays a**ress the patients concerns as you go? al.ays )e honest .ith him%
7onFt .aste time on a complete historyO mo5e from stage to stage ;uickly an* efficiently%
Al.ays .ash your han*s )efore the physical examination part%
Al.ays remem)er to *rape the patient .ell%
Try to *o a running commentary .ith the patient% This means explain .hat you are going to *o )efore
actually *oing it an* if possi)le explain things as you go% (or example: @o. I am going to listen to the heart
soun*s )y placing the stethoscope on *ifferent areas of your chest%
&ne *ifficult thing I face* *uring the exam is the flo. of thoughts% $ou cannot stop e5en for a secon* in
front of the patient to think%
So I *onFt ha5e the chance to re5ie. the fact that .hether I ha5e aske* all the important ;uestions or not% To
counteract this I use* a techni;ue .hich is as follo.s: 9hen e5er you are examining the patient like listening
to the heart or )reath soun*s << thatFs it << preten* you are listening to these things .ith full concentration )ut
think of all the things you ha5e misse* in the history% Any.ay most of the fin*ings in the stan*ar*i=e*
patient .ill )e normal% So *onFt .orry that you .ill miss fin*ings%
Help the patient mo5e from one position to another%
Make sure the P'E is focuse* to the chief complaints%
Stay focuse* an* calm throughout the exam%
At the en* of e5erything? help the person tie the go.n? sit up? an* then seat your self on the footstool% Eoo*
closure is extremely important% Eoo* closure in5ol5es *iscussing your possi)le *eferential *iagnosis >7onFt
panic if you ha5e only one? ne5er say that is the *iagnosis? instea* play aroun* .ith it? say that this is one of
the se5eral possi)ilities that you are consi*ering an* that you .ill nee* to .ait for the *iagnostic test results!
Take time to explain your fin*ings an* your *iagnostic plan of management .ith the patient at the en* of the
encounter%
Try to tell patients that you are concerne* a)out him an* .oul* like to *iscuss his con*ition further .ith the
in5estigation reports
Make sure the S%P un*erstan*s e5ery thing you ha5e planne* for him%
8e sure to ask a)out risk factors for all patients an* counsel on stopping if the patient is .illing%
The stan*ar*i=e* patient *efinitely asks you certain ;uestions% 7onFt e5a*e them% 8e rea*y to ans.er
challenging ;uestion .ith common sense% ItFs 5ery important that you )e honest in your ans.ers% Tell the
patient that you .ill get )ack to him .ith the ans.ers if you are not sure of an ans.er%
"2
o Ex% -ike .hen you are *ealing .ith a case of pericar*itis the patient may ask AIs this an episo*e of
heart attackBA
$our reply shoul* )e <<< It really *oesnFt look like an episo*e of heart attack )ecause the pain is chronic?
postural? an* increase* )y )reathing% Although I cannot rule out this possi)ility completely% So I am going to
*o certain in5estigations? .hich shoul* help me? rule out this con*ition%
8efore lea5ing? ask if there is anything else they .oul* like to talk to you a)out%
A *ifficult patient is one .ho .ill not ans.er your ;uestions in a polite manner? )ut you shoul* remain calm
an* try to extract the )est history possi)le%
8eha5e like a professional *octor *oing your 6o) an* mo5e on from there% :emem)er that they ha5e )een
tol* to act like that%
Try to *etermine .hy he is )eha5ing in a particular fashion from him%
-ike if he is angry? you coul* say< AMr% xy=? you seem to )e angry? coul* you please tell .hy that is so an* is
there any .ay I can help you%A
8e confi*ent an* thatFs the key to success? ne5er lose your cool%
A5oi* the temptation to )e o5er<frien*ly or 6ocular .ith the patients%%%% remem)er youF5e spent 0## plus
)ucks to take this exam? not to mention a fe. ### more to get to Philly an* for accommo*ations etc%
Memori=e the patient note format in the CSA orientation Manuel%
Mno. the a))re5iations gi5en in the EC(ME )ooklet an* practice using them%
:ransportation
If you arri5e )y airplane? most of the people use -a*y -i)erty% It is cheap>V4<#! an* 5ery relia)le% $ou only
ha5e to .ait ten minutes from the time you calle* them% $ou go to )aggage claim area? fin* the *esk
AEroun* TransportationA an* ask the clerk there for -i)erty shuttle% Then you call from that phone A02A an*
say? that you nee* shuttle to ACenter CityA or hotel you plan to stay an* theyFll *eli5er you *oor to *oor for
V4 an* possi)le tip%
9hen you ha5e checke* out from the room? 6ust call them again >they pro5i*e phone W an* hotels also ha5e
it! an* in ,<"# minutes youFll get a shuttle )ack to your terminal% Taxi as t.ice as expensi5e? su).ay or
)uses cheaper a little )it )ut makes a lot of trou)le fin*ing your .ay to the hotel in unkno.n city%
'ccommodation
(or accommo*ation .e .oul* strongly recommen* 7i5ine Tracy% So I calle* to 7i5ine Tracy? they nee*
Money &r*er to reser5e the room an* room costs from V"# to V,#? *epen*ing on )athroom >pri5ate or
share*!? room >pri5ate or share*!? T3 etc% (or a .eek it .oul* cost from V+# to V##? un)eata)le price% 3ery
clean an* calm hotel? people there are religious group )ut *o not )other you% Some restrictions )ut .hat a
point: you 6ust nee* sleep night )efore the exam an* thatFs all%
CSA center is 6ust aroun* a corner? in ,# meters to other si*e? Chestnut an* "+ you ha5e pi==a restaurant an*
0/hours foo* mart .ith coffee? *onuts? 6uice an* .hate5er else you nee* to get some tonus )efore the test%
8ook the rooms in 7i5ine as early as possi)le% &ther.ise you .ont get rooms% They only take cash an* you
can only reser5e a room if you sen* them a cash *eposit%
Most of the times you .onFt get rooms in International house an* Sheraton an* they are 5ery expensi5e%
Please ask them their check in times? .hile )ooking the room% &ther.ise you ha5e to .ait until " P%M%
7etails of the hotel a**resses an* phone num)ers .ill )e a5aila)le in CSA )ooklet%
=efore the e?am
(irst of all? keep in min* an* try to stay calm a)out the fact that you .ill )e 6ust a num)er in a her* )eing put
through the thing? you completely gi5e up your in*i5i*uality .hen you take the exam% Try not to take that
personal% It is 6ust the .ay it is%
E5erything is .ell organi=e* an* time*? the CSA proctors are 5ery frien*ly )ut also efficient%
"4
Try to arri5e at the test center "# minutes early? e5en though they .ill only put you in a room together .ith
e5ery)o*y else an* .ait until e5eryone has arri5e*%
They start the registration not )efore 4%"#% $ou .ill 6ust sit aroun* getting e5en more ner5ous if you get there
early% At 4%"# they start registering? you ha5e to present your permit >that you got after you confirme* your
exam *ate 5ia phone or internet! an* one I7? like passport or *ri5erFs license%
If you *o not ha5e the permit .ith you? no s.eat? you .ill 6ust nee* t.o forms of I7% $our name is on their
list% Then you get an I7 )a*ge? >.hich is the pink little slip you sent in .ith a photo .hen you applie* for the
CSA? I .as 5ery em)arrasse* )ecause my picture on it .as terri)le!? to put on your chest pocket of the la)
coat? an* also a )ig arm )an* .ith a num)er on it to .ear on the left upper arm<something I foun* 5ery
*istur)ing%
Then they han* out a confi*entiality agreement? t.o copies? one for you to keep after they han* it out after
the Exam? an* pages of note paper for the encounters an* a pen that you are only to use *uring the .hole
time% I am not ki**ing% The room .as packe* .ith 00 people? a group of in each )lue an* pink arm)an*
*i5ision% It took a .hile until I reali=e* that they .oul* run t.o groups parallel? meaning t.o sets of S%PFs
for each group%
Aroun* 1%##am e5ery)o*y .as registere* an* got the clip)oar* .ith pen an* note paper%
E5ery)o*y .as aske* if .e ha* our e;uipment? they e5en offere* la) coats? stethoscopes an* .atches in case
someone forgot a)out it%
9e then entere* the orientation room? ha* to sit *o.n in or*er of the num)ers at a large K form of ta)les%
9e .ere aske* to take e5erything out an* put on the ta)les .hat me might nee* *uring the exam as
e5erything else .oul* )e store* an* locke* a.ay *uring the exam? the storage room is small? no place for
luggage? 6ust tiny little cu)icles? num)ere* again? 6ust for )ackpacks%
A sli*e sho. orientation starte*? .ith familiar an* some ne. info:
% $ou are allo.e* to palpate axillary an* inguinal lymph no*es inclu*ing the femoral pulse%
0% Postural signs an* 8P repeat can )e or*ere* in the .ork<up% 7onFt .aste your time for measuring
those things%
Although it .as emphasi=e* that using the glo5es is fine I .oul* still recommen* .ashing the han*s? they
ha5e only one si=e of glo5es? an* seriously? in my .hole career as a *octor I ha5e ne5er seen any)o*y using
glo5es to palpate the a)*omen or percuss the lung%%%%so .hy *o it no.? I .as a)le to .ash my han*s .ithin
0# secon*s%%
At one si*e of the orientation room an exam room .as set up an* there .as ample opportunity to use the
instruments? try out the )ench? the *rape? the forks etc% Duestions .ere .elcome an* ans.ere* nicely%
Then after a last )athroom )reak .e finally starte*? it .as a)out 1%,#am alrea*y%
The only thing you can )ring yourself is the la) coat an* stethoscope? e5erything else is pro5i*e*%
Here is .hat is presente* in the room? ho. any)o*y shall ha5e time to use all of this is )eyon* my
imagination though:
SnellenFs 5isual chart at the .allO t.o tuning forks .ith *ifferent fre;uenciesO cotton s.a)s an* toothpicksO
tongue *epressorsO reflex hammerO ophthalmoscopeO otoscopeO )loo* pressure cuff
:he actual e?am
There is a long )ut narro. corri*or of a)out ten feet .i*th? to each long si*e a)out , *oors%
The examinees face the *oors% 8et.een the *oors there are small .orkstations settle*? .here you .ill .rite
the patient note )efore .alking up to the next *oor%
9hen you face the *oor? there is a plastic )ox on the *oor% It *oes contain the *oor.ay info% 9hen
e5ery)o*y is settle* an* rea*y? you get the signal to start your encounter%
This is .here the fifteen minutes startLLL $ou ha5e to open the )ox at the *oor an* rea* the *oor.ay info%
The *oor.ay info is scarce? it .ill tell you the full name? age? setting >E:? office!? chief complaint an* 5itals
>8P? pulse? temp? respiration!%
At the )ottom they tell you .hat to *o? 6ust like in the info )ooklet% The time you spen* rea*ing an* taking
notes 7&ES count to the , minutes%
7o not rush into the room? )ecause once you enter? you .ill )e totally occupie* )y the SP%
Try to spen* a)out /, secon*s in front of the *oor to make a mental note of *ifferential *iagnosis% This is
extremely important%
"1
9hen you are in the room time flies% So )u*get your time accor*ingly%
$ou *o @&T ha5e to .rite e5erything *o.n? there is a secon* copy of the *oor.ay info in the room%
All patients .ill )e sitting on the exam ta)le in their go.n .hen you enter the room%
In the tiny rooms there is a chair right in front of the )ench .here you can sit *o.n%
Also? to the si*e of the )ench there is a little stool .ith the *rape fol*e* on top of it% In the corner there is a
little .orkstation .ith computer on it? )ut not for you? it is for the S%PFs to gra*e your performance%
At ten minutes you hear the signal of , minutes remaining for this encounter% Then at , minutes there is a
signal that this encounter is o5er an* you ha5e to lea5e the room% Still? you *o not ha5e to 6ust cut off the
sentence an* run out? you still can finish the encounter .ith a ;uick )ye<)ye? after a)out ten secon*s they
nicely knock on the *oor to get you out%
:ight after the , minutes the ten minutes for the patient note start% After 4 minutes? an* this .as 5ery
helpful? there is a signal to let you kno. that there are 0 minutes remaining for your note%
After the ten minutes you ha5e to put *o.n the pen an* .ait for the proctors to collect the patient note an*
the piece of note paper% 9hile .riting the note you can still get up? open the *oor.ay info again an* rea* it? I
*i* that t.ice an* it .as fine to *o so as long as you sli*e it shut again%
Then the next encounter *oes start only after e5ery)o*y has .alke* up to the next *oor an* positione* again%
This gets into a nice routine an* it is o5er sooner than you think%
After / patients there .as a "# minute lunch )reak? then after another / cases a , minute )reak%
The foo* there .as excellent? a 5ery goo* cater ser5ice? e5en 5egetarian%
They offere* san*.iches? fruit? cookies? sala*? )rea*% A feast if your stomach .erenFt so occupie* .ith
ner5ousness% Also? there is no nee* to )ring *rinks? they ser5e* col* an* hot .ater? tea? coffee? soft *rinks%
Seriously? you *o not ha5e to .orry a)out getting foo* to )ring%
It .as more than sufficient an* e5ery)o*y thought so%
After the exam they ask you to complete an anonymous ;uestionnaire? )ut still they ask you to put your
KSM-E num)er on there%
9e ha5e no clue a)out this? .hy gi5e them my num)er if it is suppose* to )e anonymous%%%%B
They ask general things a)out your opinion of the exam? an* also a)out your i*eas of *oing the notes at the
computer%%%
The exam usually finishe* at "%/,pm for morning session% %
Most of the people ha5e no i*ea ho. they *i*? there is 6ust no time at all to nearly get e5erything aske* an*
*one the .ay you .oul* like to%%%6ust remem)er this%%%no matter .hat you *i*? you .ill feel frustrate*
after.ar*s%
It is completely normal? I seriously think this is one of the things they test? ho. .ell you can cope .ith time
pressure an* frustration%%%%
The proctors .ere 5ery .arm an* effecti5e? they really trie* to make the thing as pleasant as possi)le%
6ote: This is the actual exam picture .hen .e took the exam% 9e greatly appreciate if you can pro5i*e change*
information after your exam through our fee* )ack form%
F',
#. %o the 7.2Es show you cards as in O75< e?am0
The S%PFs *o not use car*s to tell you .hat the a)normal fin*ing shoul* )e% The 5itals are poste* outsi*e the
*oor? an* if thereFs an a)normal 5ital sign? say a high )loo* pressure? you are instructe* *uring the
intro*uction to take these 5alues as accurate
2. Fill we be able to detect any physical findings /li@e bruisesB redness..) on 7.2Es0
Some of the a)normal physical exam fin*ings can )e acte* out? like a)*ominal pain? .eakness? etc% Some
ha* a patient .ith a history of fall an* ha* a )ig )ruise >.hich .as o)5iously 6ust make<up!% Mnee has )een
painte* in re* color to sho. the inflammatory con*ition% In some instances the S%P > case of sore throat! can
ha5e real enlarge* tonsils% So look carefully%
/#
3. + ha"e a problem of stutteringB will that ha"e any effect on my e?am0
-et CSA people kno. a)out your con*ition? you can *o it either )y filling in the han*icappe* section in the
CSA application or )y sen*ing them a letter later on *escri)ing your pro)lem% They .ill respon* to you an*
.ill also inform the S%PFs% Cust to )e on safe si*e tell the S%PFs a)out your pro)lem )efore you start > of course
after you greet an* intro*uce your self!%
. + heard that there is problem for accommodation for couples in few hotelsB is it true0HHH
The only pro)lem is accommo*ation in 7i5ine Tracy% Since it lo*ges .omen on one floor an* men on
another floor? so you .oul* ha5e to get t.o rooms% @ot to .orry all the other hotels are rea*ily a5aila)le if
you )ook earlier? only pro)lem is they might )e a little more expensi5e although it might .ork out to )e
more con5enient for t.o people%
9uidance for better practice
The gui*ance .e gi5e here .ill )e 5ery helpful for you if you can manage to get a partner > not necessarily a
me*ical stu*ent? any frien* .ill *oI%your .ife' hus)an*!%
$ou nee* to ask your partner >SP! to rea* his'her notes first% It is e5en easier if he 'she can mark all the
positi5e things
Time your practice session? this is 5ery important% An* most important is that your time starts )efore you
enter the room% So you ha5e ,min from out si*e the room%
After the session is complete* >i%e% .ithin , minutes! you go an* see the checklist for that case% If you *o
more than +,U usually you .ill pass in the exam% 8ut .e a*5ise you try to make at least 2,U *uring the
practice session% In the exam o)5iously you .ill miss many things more easily )ecause of tension% So *onFt
.orry if you miss in the exam )ut not in the practice session% The only .ay to o5ercome this pro)lem is
practice? practice an* practice %%% 9e a*5ise e5eryone to practice these cases at least " times in a time*
manner%
Please *o not skip any part? as you nee* to time e5ery thing for each case%
/