Professional Documents
Culture Documents
General Information...............................................................
Registration for NAC OSCE................................................
Fees.........................................................................................
Examination station...............................................................
NAC OSCE scoring..............................................................
Sample of Therapeutic written test........................................
Sample clinical case station....................................................
Therapeutic Guidelines Medicine
Cardiology..............................................................................
Dermatology...........................................................................
Endocrinology........................................................................
Gastroentermogy....................................................................
Hematology............................................................................
Infectious Diseases.................................................................
Neurology...............................................................................
Otolaryngology......................................................................
Pulmonology..........................................................................
Rheumatology........................................................................
Nephrology/Urology..............................................................
Emergency Medicine..............................................................
Counseling (smoking/alcohol)..............................................
Obstetrics & Gynecology
Sexually transmitted infections..............................................
Urinary tract infection............................................................
Vulvovaginitis.........................................................................
Pelvic inflammatory disease...................................................
Dysfunctional uterine bleeding.............................................
Dysmenorrhea........................................................................
Endometriosis........................................................................
Hormone replacement therapy..............................................
Emergenqr contraception.......................................................
Group B Streptococcus in pregnancy....................................
Pregnancy induced hypertension...........................................
Ectopic pregnancy..................................................................
Hyperemesis gravidarum........................................................
Drugs contraindicated in pregnancy......................................
Pediatrics
Acute bronchiolitis.................................................................
Acute otitis media..................................................................
Asthma...................................................................................
Bacterial tracheitis..................................................................
Bacterial pneumonia...............................................................
Croup (Laryngotracheobronchitis)........................................
Epiglottitis..............................................................................
Streptococcal pharyngitis (Group A streptococcus)..............
Whooping cough (Pertussis).................................................
Bacterial meningitis................................................................
Febrile seizures.......................................................................
Urinary tract infection............................................................
Allergic reaction......................................................................
Anemia...................................................................................
Dose of tylenol.......................................................................
Immunization schedule..........................................................
TABLE OF CONTENTS
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Psychiatry
Delerium.....................................................................................................................................52
Mania..........................................................................................................................................53
Panic disorder..............................................................................................................................53
Social phobia...............................................................................................................................54
General anxiety disorder.............................................................................................................54
Obsessive compulsive disorder....................................................................................................55
Post traumatic stress disorder......................................................................................................55
Dementia.....................................................................................................................................55
Depression...................................................................................................................................56
Psychosis......................................................................................................................................56
Mood stabilizers..........................................................................................................................57
Medications causing sexual dysfunction.....................................................................................58
Substance abuse...........................................................................................................................59
Clinical Examination
Abdominal ..................................................................................................................................63
Cardiovascular ............................................................................................................................65
TABLE OF CONTENTS
Infertility....................................................................................................................................121
OCP counseling.........................................................................................................................122
Pelvic inflammatory disease.......................................................................................................123
Placenta previa...........................................................................................................................124
Pre eclampsia..............................................................................................................................125
Pediatrics
Failure to thrive..........................................................................................................................126
Febrile seizure............................................................................................................................127
Measles......................................................................................................................................128
Neonatal jaundice.......................................................................................................................129
Primary nocturnal enuresis........................................................................................................130
Pyloric stenosis...........................................................................................................................131
Speech delay...............................................................................................................................132
Psychiatiy
Anorexia.....................................................................................................................................133
Bulimia.......................................................................................................................................134
Delirium.....................................................................................................................................135
Dementia....................................................................................................................................136
Depression..................................................................................................................................137
Mania.........................................................................................................................................138
Panic attack................................................................................................................................139
Schizophrenia.............................................................................................................................140
Suicide........................................................................................................................................141
Surgery
Back Pain....................................................................................................................................142
Basal cell carcinoma...................................................................................................................143
Benign prostatic hyperplasia......................................................................................................144
Carpal Tunnel Syndrome...........................................................................................................145
Deep Vein Thrombosis..............................................................................................................146
Diabetic foot..............................................................................................................................147
Difficulty swallowing (Ca oesophagus )....................................................................................148
Hematemesis..............................................................................................................................149
Neck swelling.............................................................................................................................150
Pain abdomen.............................................................................................................................151
Peripheral vascular disease.........................................................................................................152
Post operative fever....................................................................................................................153
Solitary lung nodule...................................................................................................................154
Thyroid mass..............................................................................................................................155
Trauma.......................................................................................................................................156
Counseling
Breast feeding.............................................................................................................................159
Child abuse................................................................................................................................160
Domestic violence......................................................................................................................161
Hormone replacement therapy..................................................................................................161
Mammogram.............................................................................................................................163
Immunization.............................................................................................................................164
Obesity.......................................................................................................................................165
Smoking.....................................................................................................................................167
TABLE OF CONTENTS
Fees
Application Fee: $200 which is non-refundable, NAC OSCE Fee in Ontario: $1850 and Exam Date Change
Fee: $100
All fees are in (CAD) Canadian Dollars.
Examination station
The format for the National Assessment Collaboration (NAC) Objective Structured Clinical Examination
(OSCE) consists of 12 stations based on presentations of clinical scenarios. For a given administration,
each candidate rotates through the same series of stations. Each station is 10 minutes in length with two
minutes between stations.
At each station, a brief written statement introduces a clinical problem and outlines the candidate's tasks
(e.g. take a history, do a physical examination, etc.). In each station, there is at least one standardized
patient and a physician examiner. Standardized patients have been trained to consistently portray a
patient problem. Candidates should interact with standardized patients as they would with their own
patients.
The physician examiner observes the patient encounter. For most stations, the candidate will be asked to
respond to a series of standardized oral questions posed by the physician examiner after seven minutes
with the standardized patient. There are no rest stations.
Orientation videos http://www.mcc.ca/en/video/QEII-Orientation/index.html
The examination includes a separate written test of candidates' therapeutic knowledge. This component
lasts 45 minutes and consists of 24 short-answer questions testing the candidates' knowledge of
therapeutics for patients across the age spectrum and related to pharmacotherapy, adverse effects,
disease prevention and health promotion.
The candidate's total examination score will be determined by combining the scores on the OSCE
component with the scores on the therapeutics component. The OSCE score contributes 75 per cent of the
total score and the therapeutics score contributes 25 per cent of the total score. For reporting purposes,
the NAC total examination scores are reported on a scale with a distribution ranging from 0 to 100 with a
fixed passing mark of 65.
Question: An otherwise healthy 65 year old woman presents with a 3 week history of aching and morning
stiffness in both shoulders with difficulty dressing. She has no temporal artery tenderness, headache, jaw
pain or visual disturbance. Her ESR (Erythrocyte sedimentation rate) is 100 and you have made the
diagnosis of POLYMYALGIA RHEUMATICA (PMP).
What would you choose as the drug of first choice for initial medical therapy? (Drug, dose, route of
administration and duration are required.)
Answer:_______________________________________________________
Answer key the marker receives:
PREDNISONE 7.5 - 20 mg PO od for 2-4 weeks following resolution of symptoms
Question: An otherwise healthy 55 year old male with a history of childhood chickenpox" presents with a 2
day history of painful unilateral vesicular eruption in a restricted dermatomal distribution. You make a
diagnosis of HERPES ZOSTER (shingles).
What would you choose as the drug of first choice to promote healing and lessen the neuropathic pain?
(Drug, dose, route of administration and duration are required.)
Answer:__________________________________________________________
Answer key the marker receives:
VALACYCLOVIR (VALTREX ) 1000 mg PO tid X 7 days OR FAMCICLOVIR (FAMVIR ) 500 - 750 mg PO tid X
7 days OR ACYCLOVIR (ZORIVAX ) 800 mg PO 5X / day X 7 days)
Therapeutic Guidelines
This isa
Atrial Fibrillation
1. To control rate:
Inj Metoprolol 5 mg bolus IV, followed by infusion at 0.05 mg/kg/min, increasing as needed to 0.2
mg/kg/min.
Inj Diltiazem 20 mg bolus. Maintenance infusion of 5-15 mg/hr.
Inj Verapamil 5-10 mg IV over 2-3 min, repeated once after 30 mins.
Tab Amiodarone (in case of heart failure):
Loading dose: 800 - 1600 mg PO in divided doses until response; till max 1000 mg/day divided bid-tid.
Maintenance: 200 mg PO od.
2. To prevent thromboembolism: Assess with CHADS 2 score
No risk: Tab Aspirin 81-325 mg PO od.
1 moderate risk: Tab Aspirin 81-325 mg PO od or Tab Warfarin 2-15 mg PO od to maintain INR 2-3.
>1 moderate risk or very high risk: Tab Warfarin 2-15 mg PO od to maintain INR 2-3.
3. To control rhythm:
Tab Flecainide 300-400 mg PO bolus dose, maintenance: 50-150 mg PO bid. (First choice)
Dyslipidemia
1. HMG Co A Inhibitors:
Atorvastatin : Tab Lipitor 10-80 mg qhs
Rosuvastatin : Tab Crestor 10-40mg qhs
S/E: Gl symptoms, rash, pruritus, increased liver enzymes, myositis.
C/I: active liver disease, muscle disease, pregnancy.
2. Fibrates: increased TG (triglycerides)
Fenofibrate : Tab Lipidil 67-200 mg/d
3. Bile acid sequestrants : increased LDL
Tab Colestipol 5-30g/day
4. Cholesterol absorption inhibitors:
Tab Ezetimibe lOmg /day.
Lipid Risk
LDL
Total cholesterol/HDL
HIGH (lOyrCAO >20%)
Target LDL-<2.0
Target <4
MODERATE (10yr CAD > 10-19%)
Treat if LDL- >3.5
Treat if >5
LOW (10yr CAD <10%)
Treat if LDL ->5
Treat if >6
High Risk : All with CAD, CVD, most diabetes cases & chronic renal disease.
Hypertension
Non pharmacological treatment :
Smoking cessation: smoking aggravates hypertension and remains the major contributor to
cardiovascular disease in people under 65 years.
Weight reduction : Maintain BMI<27, particularly in patients with glucose intolerance
Alcohol restriction.
Sodium restriction <150mmol/day.
Blood pressure risk factors
Consider treatment if BP
BP target
No risk factors
>160/100
<140/90
isolated systolic hypertension
SBP>160
SBP<140
Moderate-High risk patient
>140/90
<140/90
Diabetes or Renal disease
>130/80
<130/80
Acne
Mild : <20 comedones (whiteheads/blackheads) or <15 inflammatory papules, or a lesion count <30
Moderate : 15-50 papules and pustules with comedones, cysts are rare, lesion count ranges from 30-125
Severe : Primarily nodules and cysts,also present are comedones, papules and pustules, scarring is
present, lesion count >125
T
0
P
i
Benzoyl Peroxide (Antibacterial/Keratolytlc)
Dose : apply to entire affected area qhs or bid
Indication: 1st line medication for mild- moderate acne.
S/E : contact dermatitis, dryness, erythema, burning & pruritis
c
A
Tretinoin (Retinoid)
1st line treatment for mildS/E : erythema, dryness,
off/cycle
hirsutism, late onset acne
E
M
Isotretinoin
Severe nodulocystic acne,
Teratogenicity : ocular
1
Bums
Initial assessment of ABCs , consider the need for early intubation if airway is compromised.
Humidified 02 if any suspicion for inhalational injury.
Oxygen 100% if known carbon monoxide exposure of fire in an enclosed space. (Half life of hemoglobin
will drop from 330 to 90 mins).
Establish IV access.
Fluid resuscitation : Parkland formula 4mL/kg/%BSA burn, Vi over 8 hours and rest over 16 hours
Nasogastric tube drainage for ileus.
Bladder catheterization to monitor urinary output, minimum lmL/kg/hr.
Tetanus prophylaxis : 0.5 mL tetanus toxoid IM in previously immunized and 250 units TIG IM if
unimmunized.
Psoriasis
Topical Preparations :
1. Topical Corticosteroids :
High Potency Topical Steroids (Usually indicated)
Very high potency: e.g. Clobetasol (Temovate)
High potency: e.g. Fluocinonide (Lidex)
Low Potency Topical Steroids (Alclometasone dipropionate) usually indicated in
Face
Genitals
Maintenance Therapy
2. Vitamin D based topicals :
Calcipotriene (Dovonex)
Used in combination with Topical Corticosteroids
3. Retinoid based topicals :
Tazarotene (Tazorac)
Biological agents
Tumor necrosis factor (TNF) receptor blockers
Etanercept (Enbrel)
Infliximab (Remicade)
Other mechanisms
Alefacept (Amevive)
Efalizumab (Raptiva)
Thiazolidinedione (Avandia, Actos) - experimental
Appears effective in Psoriasis even in non-diabetics
Only small trials support to date
Cellulitis
Cause : P Hemolytic Streptococcus , Staphylococcus
Treatment : Tab Cloxacillin 500mg PO qid x 10-14 days
If patient is allergic to penicillin : Tab Cephalexin 500mg PO qid 10-14 days OR Tab Clindamycin 300mg PO
qid x 10-14 days
Pediculosis
Permethrin 1% - wash hair with regular shampoo, then apply permethrin and leave for 10 mins then rinse
Pyrethrins with piperonyl butoxide
Lindane 1% C/I in neonates, young children and pregnant women, causes neurotoxicity
Wash all clothes and linen in hot water, then machine dry.
Scabies
Permethrin 5% - massage into all skin areas, from the top of the head to the soles of the feet, leave for 814 hours then wash off.
Crotamiton 10%
Scabene (aerosol spray)
Lindane : used only if allergic to permethrin.
Treat family and contacts.
Wash all clothes and linen in hot water, then machine dry.
Tinea Cruris/Pedis (Jock itch/Athlete's foot)
Clotrimazole 1% cream apply bid
Ketoconazole 2% cream apply bid
Potassium
Do not administer Insulin until potassium >3.3
Give KC1 40 mEq/hour IV until corrects
Serum Potassium 3.3 to 5.0 mEq/L
i. Standard replacement: 20-30 mEq per liter
Serum Potassium >5.0 mEq/L
i. Do not administer any potassium
ii. Monitor every 2 hours until <5.0
Bicarbonate
Indications
i. ABG pH < 6.9 to 7.0 after initial hour of hydration
ii. Other contributing factors
Shock or Coma
Severe Hyperkalemia
Hyperthyroidism
Tab Propylthiouracil(PTU) 100 mg PO tid, to max 150 mg 6-8 hours.
Tab Methimazole 10-30 mg PO od.
Medications associated with Hyperthyroidism:
Excess Thyroid hormone intake Dietary Iodine Amiodarone
Hypothyroidism
Tab L-Thyroxine 0.05-0.2 mg/day
Medications associated with Hypothyroidism:
i. Inorganic iodine
ii. Iodide
iii. Amiodarone
iv. Lithium
Hyperprolactinemia
Tab Bromocriptine 1.25-2.5 mg PO od, increase by 2.5 mg/day q3-7days to max 15 mg/day.
Tab Cabergoline 0.25 mg PO twice weekly, may increase by 0.25 mg q4weeks up to max lmg twice
weekly.
4. Gastroenterology
Appendicitis
Perioperative for 24hrs
Inj Ampicillin l-2g IV q4-6h.
Inj Flagyl 500mg IV bid.
Inj Gentamicin 3-5mg/kg/day q8h (monitor creatinine levels).
NPO
Acute Gastroenteritis
Tab Flagyl 500 mg PO bid x 5 days.
Tab Ciprofloxacin 500 mg PO bid x 3 days.
Tab Norfloxacin 400 mg PO bid x 3 days.
Oral rehydration solution.
Acute Gastroenteritis Causes (Watery diarrhea)
E. Coll (Traveler's diarrhea) CMV
Cryptosporidium Giardia lamblia
1. Mild to moderate:
Tab Mesalamine 800 mg PO tid. Maintenance dose 3.2 - 4g per day.
Tab Sulfasalazine 250 mg per day and increase up to 2 g per day. Maintenance dose is 500- 1000 mg PO
qid with food.
2. Moderate to severe:
Tab Prednisone 40 mg PO qid x 8-12 weeks and taper gradually.
Tab Azathioprine 2-2.5 mg/kg/day. Used for maintenance while tapering corticosteroids. Diverticulitis
Inj Flagyl 500mg IV bid.
Inj Ciprofloxacin 500mg IV bid.
Helicobacter Pylori
1. HP-PAC (7 blister pack) 7-14 days
Tab Lansoprazole 30mg PO bid +
Tab Clarithromycin 500mg PO bid +
Tab Amoxicillin lg bid
2. 2nd LINE Quadruple : 14 days
Tab Lansoprazole 30mg PO bid
Tab Flagyl 500mg PO bid
Tab Tetracycline 500mg bid
Tab Bismuth 525mg PO qid
5. Hematology
Anemia
Iron Deficiency Anemia : Tab Ferrous fumarate(Palafer) 300 mg PO qd OR Tab Ferrous Sulfate 325 mg PO
qd
Megaloblastic Anemia : Tab Ferrous Fumarate 300mg PO qd + Tab Folic acid l-5mg PO qd +
Inj B12 1000 meg q monthly or 1000 - 2000 microgram PO.
6. Infectious Diseases
2 months.
2. Continuation Phase: Tab Isoniazid 300 mg + Tab Rifampin 600 mg for 4 months.
3. Add Tab Pyridoxine (Vit B6) 50 mg PO OD.
Rabies
Post exposure prophylaxis:
Wash wound with soap and water.
Human Rabies Immunoglobulin 20 IU/kg IM stat and half dose into the wound.
Rabies vaccine 1 ml IM on days 0,3,7,14,28.
Inform Public Health.
Capture animal & observe x 10 days, then examine brain for negri bodies.
Tetanus Prophylaxis : Based upon Tetanus immunization status History of tetanus Immunization
Clean, minor wounds
All other wounds
Td or Tdap* 0.5ml
Tig** 250U
Td or Tdap*
Tig
Uncertain or < 3 doses of an immunization
Yes
No
Yes
Yes
> 3 doses received in an immunization
Not
No
No
No
* Adult-type combined tetanus and diphtheria toxoids or a combined preparation of diphtheria, tetanus and acellular pertussis.
If the patient is < 7 years old, a tetanus toxoid-containing vaccine is given as part of the routine childhood immunization. **
Tetanus immune globulin, given at a separate site from Td (or Tdap) t Yes, if > 10 years since last booster.
Yes, if > 5 years since last booster. More frequent boosters not required and can be associated with increased adverse events.
The bivalent toxoid, Td, is not considered to be significantly more reactogenic than T alone and is recommended for use in this
circumstance. The patient should be informed that Td (or Tdap) has been given.
7. Neurology
Seizures
1. Acute Management:
Inj Diazepam 5-10mg IV q2-3mins till seizure stops.
Inj Phenytoin 20mg/kg IV at 50mg per min.
Inj Phnobarbital 20mg/kg IV at 50-75mg/min
If all fails then rapid sequence intubation.
2. Primary Generalized & Partial seizures:
Tab Phenytoin: Loading 300mg PO q4h x 3 doses, then 300mg PO qhs.
Tab Valproate: Loading 15mg/kg/day, increments by
5-10mg/kg/day qweekly, till seizures are controlled.
Tab Carbamazepine: Start 100-200mg PO od-bid, increments by 200mg/per q2d, if needed till max
800mg-1200mg per day.
3. Absence Seizures:
Tab Ethosuximide 500mg PO daily in divided doses, increments by 250mg/day q4-7d pm till max 1500mg
per day.
Meningitis
Investigations : CT then LP, CSF analysis, blood C&S, neurology consult
Empirical adult antibiotics : 3rd generation cephalosporins + vancomycin + ampicillin Inj Ceftriaxone 2g
IV ql2h
Inj Dexamethasone lOmg q6h IV x 4 days for pneumococcal meningitis Meningococcal: give contacts Tab
Rifampin 600mg PO ql2h x 4 doses
IP: P~450 Interactions H: Hirsutism E: Enlarged gums N: Nystagmus Y; Yellow-browning of skin T: Teratogenicity 0: Osteomalacia I:
Interference with folic acid absorption {hence anemia) N: Neuropathies: vertigo, ataxia, headache
Fungai/TB
Pressure (cmMsO)
5-20
>30
Normal or mildly increased
Appearance
Normal
Turbid
Clear
Fibrin web
Protein {g/U
0.18-0.45
>1
<1
0.1-0.5
Glucose (mmol/l)
25-3.5
<2.2
Normal
1.6-2.5
Gram stain
Normal
60-90% Positive
Normal
Other
90% PMN
Monocytes 10% have >90% PMN 30% have >50% PMN
Monocytes
Cluster headache
Tab Triptan and Tab Prednisone at the beginning of the cycle and prophylactic treatment with Tab
Lithium(300-600mg daily initially then monitor serum levels)
Dihydroergotamine nasal spray 4mg per 1 ml. One spray each nostril and repeat ql5mins.
Migraine
1. Mild - Moderate - NSAIDS
Tab Ibuprofen 200mg tid
Tab Aspirin 600mg PO q4h
2. Moderate - Severe - TRIPTANS
Tab Sumatriptan 25mg PO & repeat q 2hrs prn
Tab Metoclopramide lOmg PO stat
3. Prophylaxis:
Tab Propranolol 60mg PO daily
Tab Amitriptyline 10-25mg PO qhs.
Tension headache
Tab Tylenol 500mg PO 4-6hrs prn.
Myasthenia Gravis
1. Anticholinesterase (Cholinergic)
Tab Mestinon (Neostigmine and Pyridostigmine): 60-120 mg q3-4h.
2. Immunosuppressive therapy
Tab Prednisone: Start at 20 mg qd, increase gradually by 5 mg every 3 days to 60mg. Continue for 3
months or until clinical improvement stops or declines. Taper gradually to every other day
Tab Azathioprine (Imuran) 2 mg/kg/day. Effective when given with Prednisone. Effect not seen for 6
months or more. Monitor CBC and LFTs.
3. Plasmapheresis (Plasma Exchange) and IV Ig: Indicated for emergent worsening/crisis.
8. Otolaryngology
Acute Sinusitis
Tab Amoxicillin 500mg tid PO x 10 days.
Decongestant: Tab Sudafed 60mg PO q6h
Nasal saline.
Acute Pharyngitis
Group A 6 Hemolytic Strep: Tab Penicillin V 300mg PO tid x lOdays
Penicillin /lctuk : lab Erydiromycia 500rnu rid x 10 days
Temporal arteritis
Start high dose Tab Prednisone 60 mg PO od until symptoms subside and ESR normal
Then 40 mg PO od for 4-6 weeks
Then taper to 5-10 mg PO od for 2 years (relapses occur in 50% if treatment is terminated before 2
years). Treatment does not alter biopsy results if the sample is taken within 2 weeks.
Monitor ESR regularly.
If visual symptoms are present, or develop during treatment, the patient is admitted and given Inj
Prednisolone 1000 mg IV ql2h for 5 days.
Polymyalgia Rheumatica Management
1. General measures
Consider concurrent Temporal Arteritis (See above)
NSAIDs
2. Prednisone (key to management)
See Corticosteroid Associated Osteoporosis
Efficacy: 90% response
11. Urology/Nephrology
Urinary tract infection (UTI)
1. Acute uncomplicated UTI: outpatient
Tab Bactrim DS PO bid x 3 days.
Tab Nitrofurantoin (Macrobid) 100 mg PO bid x 5 days.
2. Drug resistant UTI: outpatient
Tab Ciprofloxacin 500 mg bid x 3 days.
Tab Norfloxacin 400 mg PO bid x 3 days.
Tab Ofloxacin 200 mg PO bid x 3 days.
3. Acute complicated UTI: inpatient
Inj Ampicillin 1-2 g IV q4-6h and Inj Gentamicin 2mg/kg IV loading dose followed by 1.7 mg /kg q8h IV OD
Inj Ciprofloxacin 400 mg IV bid.
Switch to oral antibiotics upon improvement for a total course of 14-21 days.
2. Inpatient management: IV for 48-72 hours, then switch to oral agents. Total duration of treatment for 14
days.
Inj Ceftriaxone (Rocephin) 1-2 grams IV q24 hours.
Inj Cefotaxime (Claforan) 1 gram IV ql2 hours.
Inj Ampicillin 2 g IV q6h with Inj Gentamicin 2mg/kg IV loading dose , then 1.7mg/kg q8h.
Inj Piperacillin 3.375g IV q6h.
Acetaminophen Intoxication
Toxic level dose is more than 7.5g
Investigations : Monitor drug level stat and then q4h (Acetaminophen nomogram), LFT, INR, PTT, BUN,
Creatinine, ABG, Glucose
Rx : Charcoal/Gastric lavage as per presentation
N-acetyl cysteine 140mg/kg PO, then 70mg/kg q4h for 18 doses
Alcohol withdrawal
Treatment : Inj Diazepam 10-20mg IV
Inj Thiamine lOOmg IM then 50-100mg/day Fluid resuscitation with D5W l-2mL/kg IV
Allergic Reaction
1. Severe: Inj Epinephrine 0.3-0.5 mg SC/IM stat
2. Mild: Tab Benadryl 25-50mg PO q6h x 3d
3. Tab Prednisone 60mg PO od x 3d
Anaphylaxis
Epinephrine autoinjector (EpiPen) if available
Epinephrine IV or ETT : 1ml of 1:10,000 in adults
Inj Diphenhydramine (Benadryl) 50mg IV or IM q4-6 h
Inj Methylprednisone 50-lOOmg IV according to severity
If wheezing or spasm present : Salbutamol via nebulizer.
Digoxin Intoxication
Investigations : Plasma digoxin/digitoxin levels, ECG, electrolytes, BUN, Cr ( levels > 2.6 indicate
intoxication)
Rx : Treat arrhythmias (common with digoxin intoxication; vfib, vtach, conduction blocks)
Gastric lavage / Charcoal (lg/kg) for ingestion NaHC03 or glucose and insulin
Ventricular tachycardia : Digibind 10-20 vials if dose unknown Chronic toxicity : then Digibind 3-6 vials IV
over 30 mins.
Follow ECG, K+ Mg+, Digoxin levels every 6 hours.
Hypertensive emergency
Systolic BP > 180mmHg and Diastolic BP > 120mmHg (with signs of acute organ damage)
Investigations : CBC, electrolytes, BUN, Creatinine, ABG, Urinalysis, CXR, ECG, BP in all four
limbs, Fundoscopy, Cardiology consult.
1st Line : Inj Sodium nitroprusside 0.3 mcg/kg/min IV OR Inj Labetalol 20mg IV bolus q 10 mins.
Aortic dissection : Sodium nitroprusside + Beta blocker (esmolol)
Catecholamine excess : Inj Phentolamine 5-l5mg IV q 5-15 mins
Ml/Pulmonary edema : Inj Nitroglycerin 5-20mcg/min IV, increase by 5mcg/min every 5 min till symptoms
improve.
Hypoglycemia
Investigations : Baseline blood glucose, insulin and C-peptide, check glucose ql5 mins
until > 5mmol/L
Rx : If patient can eat/drink : give I5g carbohydrate if BG < 4mmol/L (15g glucose tabs or ZA caps
of juice or 3 spoons of sugar in water.)
NPO : give 25g carbohydrate if BG < 4mmol/L ( D50W 50cc IV push 1 amp OR D10W 500cc IV OR glucagon
l-2mg IM/SC )
Methanol/Ethylene glycol intoxication
Investigations : CBC, electrolytes, glucose, methanol level.
Rx : Ethanol 10mg/kg over 30 mins OR Inj Fomepizole 15mg/kg IV over 30 mins.
TCA Intoxication
Patients who present to the ED following psychotropic drug overdose with GCS < 8 should undergo
intubation at the earliest opportunity to prevent hypoventilation and aspiration pneumonia.
Investigations : Drug levels, ECG, ABG, electrolytes, LFTs, RFTs.
Rx : Activated charcoal lgm/kg via NG
Diazepam for seizures
Wide QRS/Seizures : NaHCOa ( 1-2 mEq/kg bolus dose and then 100-150 mEq in 1L D5/0.45% NaCl infused
100-200 ml/h IV)
Upper Gl Bleed
Stabilize patient with IVF, cross & type, 2 large bore IV cannulas.
Investigations : CBC, platelets, INR, BUN, creatinine, PTT, electrolytes, LFTs
Management : NG tube, NPO, blood transfusion if needed, upper Gl endoscopy
Inj Octreotide 50mcg loading and 50mcg per hour (for varices) SC/I V Inj Pantoprazole 50mg IV stat and
50mg q8h (gastric ulcer)
Lower Gl Bleed
Stabilize patient with IVF, cross & type, 2 large bore IV cannulas.
Investigations : CBC, platelets, INR/PTT, BUN, creatinine, electrolytes.
Management : NG tube, NPO, blood transfusion if needed, sigmoidoscopy, colonoscopy, angiogram
(for angiodysplasia)
Warfarin Intoxication
Treatment according to INR levels
INR < 5 : Stop warfarin, observation, serial INR/PTT
INR 5-9 : If no risk factors for bleeding, hold warfarin x 1-2 days & reduce maintenance dose.
OR Vitamin K 1-2 mg PO, if patient at increased risk or FFP for active bleeding.
INR 9-20 : Stop warfarin, Vitamin K 2-4 mg PO, serial INR/PTT then additional Vitamin K if needed or FFP for
active bleeding.
INR > 20 : FFP 10-15ml/kg, Inj Vitamin K lOmg IV over 10 min, increase dose of Vitamin K (q4h) if needed.
3.
4.
Nicotine gums: 2mg if < 25 cig/day, 4mg if > 25cig/day
1 piece ql-2h for l-3mths Nicotine patch:
21 mg per day for 4 weeks
14mg per day for 2 weeks
7mg per day for 2 weeks
Nicotine inhaler: 6-16 cartridges per day upto 12 weeks Bupropion(Zyban):
150mg qAM x 3days, then 150mg bid for 7- 12 weeks
Maintenance 150mg bid for upto 6 months.
General
Stop smoking during second week of medication Stop Bupropion if unable to quit by 7 weeks Minimum of 8
hours between doses More is not better
Swallow pills whole (not crushed, divided or chewed).
Alcohol cessation
Protocol: Alcohol Dependence
Lab markers
Serum Gamma glutamyl transferase or Carbohydrate deficient Transferrin
1.Initial Management
Tab Thiamine 100 mg PO qd
Tab Folate 1 mg PO qd
Multivitamin qd
Treat Hypomagnesemia if present
Seizure precautions
2.Long-Term Abstinence Programs
Alcoholics Anonymous
Detoxification centers
Halfway House
CAGE Questionnaire
C : Have you ever felt the need to CUT down on your drinking?
A : Have you ever felt ANNOYED at criticism of your drinking?
& : Have you ever felt GUILTY about your drinking?
E : Have you ever had a drink first thing in the morning (EYE OPENER}?
NOTES
Prophylaxis for HPV (for Cervical CA & warts) - Inj Gardasil IM 0,2 and 6 months.
Use GnRH Agonist along with Estrogen/Progesterone add back therapy. (To reduce the side effects of bone
loss.)
iii) Carbamazepine: Unique facial appearance and underdevelopment of the fingers, toes, and
nails; developmental delay.
iv) Phnobarbital: Cleft palate/lip, congenital heart disease, intra-cranial hemorrhage.
DES: Vaginal adenosis, adenocarcinoma, uterine malformations in female fetuses.
Lithium: Ebsteins cardiac anomaly, goiter, hyponatremia.
Misoprostol: Congenital facial paralysis with or without limb defects (Mobius syndrome) and Neural
tube defects.
Retinoids: Deformities of the cranium, ears, face, limbs, and liver, hydrocephalus, microcephaly,
heart defects, cognitive defects, craniofacial alteration, cleft palate, neural tube defects, cardiovascular
malformations and kidney alterations.
NOTES
Pediatrics
1. Acute Bronchiolitis
a. Mild distress: oral/IV hydration, antipyretics for fever, humidified 02, VENTOLIN 0.03cc in 3ml NS by face
mask q20min and then qlhr.
b. Moderate to severe distress: all the above + Ribavirin in high risk groups like congenital lung disease,
congenital heart disease, bronchopulmonary dysplasia, immunodeficient patients.
c. Antibiotics, ipratropium, systemic corticosteroids have no use.
2. Acute Otitis Media (AOM)
a) First line:
Tab Amoxicillin 80-90mg/kg/day PO divided q8h for lOd.
If allergic - Tab Azithromycin 10mg/kg/day OD for 3 days. To be given if child > 6months old.
b) Second line:
Tab Augmentin 90mg/kg/day divided ql2h for 10 days or Tab Cefuroxime 30mg/kg/day divided bid for 10
days.
Avoid FLUOROQUINOLONES under 16 years age.
3. Asthma
9 Classification (NIH recommendations)
a) Intermittent Asthma- Occasional exacerbations (Less than twice per week).
b) Mild Persistent Asthma- Frequent exacerbations (>twice weekly, but not daily).
c) Moderate Persistent Asthma- Daily symptoms with daily Beta Agonist use
d) Severe Persistent Asthma- Continuous Symptoms and frequent exacerbations.
Acute Management
i. 02 (to maintain 02 saturation > 90%).
ii. Fluids, if dehydrated.
iii. P2 Agonist : Salbutamol (Ventolin)- 0.03 cc/kg in 3cc NS every 20 minutes for 3 doses then
0.15-0.3 mg/kg (not to exceed 10 mg) every 1-4 hours as needed or 0.5 mg/kg/hour by continuous
nebulization.
iv. If Severe - Ipratropium bromide (Atrovent) lcc added to each of first 3 salbutamol masks.
v. Steroids: Inj Prednisone 2mg/kg in ER, then lmg/kg PO OD x 4d.
4. Bacterial Tracheitis
Airway management, keep child calm.
Humidified 02
Nebulized racemic epinephrine(l:1000 solution) in 3ml NS, 1-3 doses, ql-2h.
Inj Ceftriaxone 75-100mg/kg/day q24hrs + Inj Vancomycin 40mg/kg/day in divided doses every
6-8h.
1. Outpatient:
a) First-line oral agents:
i. Erythromycin 40 mg/kg/day PO divided q6h x 7-10d.
ii. Clarithromycin 15 mg/kg/day PO divided ql2h x 7-10d.
iii. Azithromycin
Day 1:10 mg/kg day 1 PO (maximum 500 mg).
Days 2-5: 5 mg/kg/day PO (maximum 250 mg).
b) Pneumococcal Pneumonia confirmed:
i. Amoxicillin 90 mg/kg/day PO divided q8h x 7-10d.
2. Inpatient:
a) First line and in critical illness:
i. Inj Cefuroxime 150 mg/kg/day IV divided q8h and
ii. Inj Erythromycin 40 mg/kg/day IV divided q6h.
b) Pneumococcal Pneumonia confirmed:
i. Inj Ampicillin 200 mg/kg/day IV divided q8h.
inf
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NOTES
52 NAC OSCE | A Comprehensive Review
Psychiatry
ANnpsYCHoncss/e
FGA>SGA
Extrapyramidal S/E - Acute dystonia, Parkinsonism, akathasia, Tardive dyskinesia. Neuroleptic Malignant Syndrome (NMS)
Sedation
Weight gain, diabetes and dyslipidemia Hyperprolactinemia and sexual dysfunction.
Mania
Mania is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. Treatment of
mania involves both acute control of severe agitation by a mood stabilizer and long term mood stabilizers.
Initially atypical antipsychotics such as Risperidone, Olanzapine or Quetiapine are effective.
First-generation Antipsychotics
Haloperidol : 5-10 mg/day PO/IM
Atypical antipsychotics
Risperidone : 2-3 mg/day PO
Olanzapine : 5-20 mg/day PO, 2.5-10 mg IM (repeat 2h and 6h prn to max of 30 mg/24 h)
Quetiapine : start with 100 mg/day PO; increase by 100 mg/day as needed to 300-600 mg/day
divided BID
2. Anxiety Disorders
Anxiety disorders are a group of conditions with exaggerated anxiousness and worry about a number of
concerns persists for an extended period of time.
Goals of treatment (Nonpharmacologic treatment)
Stress reduction and relaxation techniques such as meditation and low impact yoga is often helpful.
Cognitive behavioral therapy (CBT)
Reduction of consumption of caffeine and other stimulants.
Minimize use of alcohol
Panic disorder
Panic attack or panic disorder involves sudden anxiety that occurs without warning. Symptoms can
include chest pain, heart palpitations, sweating, shortness of breath, feeling of unreality, trembling,
dizziness, nausea, hot flashes or chills, a feeling of losing control, or a fear of dying. Panic attacks are
extremely common - 10% to 20% of the population experience a panic attack at some point in their life.
Some people start to avoid situations that might trigger a panic attack; this is called panic attack with
agoraphobia. Panic disorder refers to recurring feelings of terror and fear, which come on unpredictably
without any clear trigger.
SSRIs and SNRIs are the first choice in the treatment of panic disorders. Selective serotonin reuptake
inhibitors (SSRIs) like Citalopram, Escitalopram, Fluoxetine, Paroxetine and Sertraline are all
effective in reducing panic attacks. Serotonin norepinephrine reuptake inhibitor (SNRIs) eg. Venlafaxine is
also used in panic disorder.
There is a delay in the onset of response to these drugs which may be accompanied by initial agitation.
Combining SSRI or SNRI with a brief course of low dose benzodiazepine can increase adherence to
medication and produce rapid response.
Other medication include Tricyclic antidepressants (TCAs) eg. Imipramine, Desipramine and
Clomipramine and Monoamine oxidase inhibitors (MAOIs) eg. Phenelzine, Tranylcypromine.
blushing, sweating, and dry mouth. People with social phobia often avoid social situations that cause
anxiety.
SSRI and SNRI are mainstay drugs for the treatment for social phobia. Escitalopram, Fluvoxamine,
Paroxetine, Sertraline and Venlafaxine may be used for milder cases.
Simple stage fright or fear of public speaking may respond to low dose Propranolol lOmg taken 30
minutes before the event.
General Anxiety Disorder
Generalized anxiety disorder (GAD) is associated with continual excessive anxiety and worry about a
number of things (e.g., work, money, children, and health). There is no specific source of fear. Symptoms
can include muscle tension, trembling, shortness of breath, fast heartbeat, dizziness, dry mouth, nausea,
sleeping problems, and poor concentration. CBT is the most effective psychosocial treatment but often
takes 20 or more sessions to be effective.
SSRIs and SNRIs have become established as first line treatments for GAD. Bupropion and Pregabalin are
further choices. Low dose benzodiazepines can be used but dependence is a problem. Buspirone has a low
abuse potential and is less sedating than benzodiazepines.
Buspirone : 5mg bid-tid, up to 60 mg/day
smmnmsmmom
Confusion, disorientation, agitation, fever, diaphoresis, sinus tachycardia, HTN, mydriasis, tachypnea, myoclonic jerks, hyperreflexia, muscle rigidity, tremor, ataxia, incoordination. TREATMENT: Benzodiazepines (1 line), Serotonin Antagonists :
Cyproheptadine, Methysergide, Propranolol*
Pregabalin : Initial 150 mg/day in 2-3 divided doses, may be increased to 150 mg bid after 1 week if
necessary
Bupropion (Wellbutrin, Zyban): Use : Smoking cessation, second line Antidepressant.
Antidepressant: Start 100 mg bid x 4 days 100 m g tid.
Obsessive-compulsive disorder (OCD)
OCD involves recurring unpleasant thoughts (obsessions) and/or repetitive behaviours (compulsions).
The thoughts may be connected to the repetitive behaviours. For example, people who fear getting an
infection may constantly wash their hands. At times, however, theres no connection at all between the
thoughts and the behaviours.
CBT is the psychotherapy of choice. SSRIs : Fluoxetine, Fluvoxamine, Paroxetine and Sertraline, in the
usual antidepressant dosing range are the drugs of choice in Canada. It may take 6-8 weeks for symptoms
to improve. Second line drugs include Clomipramine, Venlafaxine, Citalopram and Mirtazapine.
Post-traumatic stress disorder (PTSD)
PTSD is associated with extreme anxiety that appears after a traumatic experience. Symptoms usually
start within 3 months of the traumatic event but may take years to start. PTSD can be associated with
sleep problems, nightmares, irritability, and anger. Feelings of guilt and unworthiness are common with
PTSD. Traumatic experiences that can trigger PTSD include wars, plane crashes, natural disasters (e.g.,
hurricane, earthquake), and violent crimes (e.g., rape, abuse).
SSRI and SNRI antidepressants have been shown to be effective in reducing the symptoms of PTSD.
Fluoxetine, Paroxetine, Sertraline and Venlafaxine are first line options.
3. Dementia
Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be
expected from normal aging. Dementia is not a single disease, but rather a non-specific illness syndrome
in which affected areas of cognition may be memory, attention, language, and problem solving. It is
normally required to be present for at least 6 months to be diagnosed.
The most common causes of dementia are Alzheimers disease and vascular dementia. It affects about 1%
of people aged 60-64 years and as many as 30-50% of people older than 85 years.
Benzodiazepines must be used cautiously in the elderly patients due to increase risk of falls and impaired
cognition.
DUMBI*
Dressing
Eating
Ambulation
Toilet
Hygiene
Shopping Housekeeping Accounting Food Making Transportation
6. Psychosis
In acutely psychotic individuals, short-acting parenteral antipsychotics either alone or in combination with
a parenteral benzodiazepine may be recommended. Liquid formulations of atypical antipsychotics may be
used as an alternative to intramuscular injections, Risperidone and Olanzapine are examples.
Atypical antipsychotics :
Clozapine - 12.5 mg PO qd or bid, titrate slowly upwards in increments of25-50 mg/day Target dose :
300 - 450 mg/day, max 900 mg/day.
S/E: Agranulocytosis, Diabetes mellitus, hypertriglyceridemia.
NOT 1st LINE Anti-psychotic. Order weekly blood counts for 1 month and then q2 weeks.
Olanzapine (Zyprexa) - Start 5-10 mg PO qd, increase in 5 mg increments weekly as tolerated, max 20
mg/day.
S/E: Mild sedation, insomnia, dizziness, early AST & ALT elevation, resdessness, weight gain, increased risk
of diabetes mellitus and hyperlipidemia.
Quetiapine (Seroquel) - Start 25 mg PO bid - tid, increase in 25- 50 mg/day increments, target 300-400
mg/day divided doses bid- tid, max 750 mg/day.
S/E: Headache, sedation, dizziness, constipation.
Risperidone (Risperdal) - Start 1 mg PO bid, slow titration 2-4 mg PO daily or divided doses bid, max 16
mg/day.
S/E: Insomnia, agitation, EPS, headache, anxiety, hyperprolactenemia, postural hypotension, constipation,
dizziness, weight gain.
Typical antipsychotics:
Haloperidol (Haldol)- 5-10 mg PO, IM, IV. May repeat q30-60mins, max 300 mg per day.
Fluphenazine (prolixin) - 2.5 mg PO bid, max 40 mg per day.
S/E - EXTRA PYRAMIDAL SIDE EFFECTS:
Akinesia - treat with Benztropine 2mg PO /IM/IV OD Dystonie reaction - treat with Lorazepam or
benztropine.
Dyskinesia
Akathesia - treat with Lorazepam, Propranolol or Diphenhydramine.
Perioral tremor
Neuroleptic malignant Syndrome - Muscle rigidity, tremor, delirium, high fever, diaphoresis,
hypertension. Discontinue drug. Give symptomatic treatment and supportive care. Treatment with
Dantrolene or bromocriptine.
Tardive dyskinesia - Blinking, lip smacking, sucking, chewing, grimaces, choreoathetoid movements, tonic
contractions of neck / back.
Treatment - Clozapine.
If severe liver dysfunction ,severe asthma, respiratory failure or age> 65 years present - Lorazepam
PO/SL/IM 1-4 mg q l-2h.
Hallucination present - Haloperidol 2-5 mg IM/PO ql-4h - max 5 doses/day along with Diazepam 20 mg x 3
doses as seizure prophylaxis.
Wernickes syndrome:Thiamine 100 mg PO OD x 1-2 weeks.
Korsakoffs syndrome: Thiamine 100 mg PO bid/tid x 3-12 months.
Opioid Intoxication:
ABCs
IV Glucose
Inj Naloxone (Narcan) 0.4 mg - 2mg IV.
Intubation and mechanical ventilation may be required for decreased level consciousness.
Cocaine Overdose:
ABCs
Inj Diazepam 2-5 mg IV/min - maximum 10-20 mg qlh ( to control seizures).
Propranolol or labetalol to treat hypertension and arrhythmia.
Hallucinogens: LSD, mescaline, psilocybin, MDMA.
Symptomatic treatment and supportive care.
Decreased stimulation.
Benzodiazepines or antipsychotics might be required.
Phencyclidine:
Room with minimal stimulation.
Inj Diazepam IV for muscle spasms or seizures.
Haloperidol to suppress psychotic behavior.
NOTES
Clinical Examination
Clinical Examination 63
Abdominal Examination
1. Steps before beginning examination
Introduce yourself : I am Dr._______, your attending physician and Ill be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.
Wash/Sanitize hands
Explain to the patient what you are about to do and gain informed consent.
Look for medical equipment/therapies (e.g. drains, colostomy/ileostomy bags).
Verbalize the steps of the examination and your findings.
Use proper draping techniques.
2. Inspection
General inspection of the patient : Is patient comfortable at rest? Do they appear to be tachypnoeic?
Examine the patients hands for presence of koilonhychia (iron deficiency), leukonychia
(hypoalbuminemia), clubbing (IBD, coeliac disease, cirrhosis), palmar erythema, tar staining or
Dupuytrens contracture.
Ask the patient to hold their hands out in front of them looking for a any tremor and then get them to
extend their wrists up towards the ceiling keeping the fingers extended and look for flapping (asterixis in
hepatic encephalopathy).
Examine the face, check the conjunctiva for pallor. Also check the sclera for jaundice. Look at the buccal
mucosa for any obvious ulcers which could be a sign of Crohns disease, B12 or iron deficiency. Also look at
the tongue. If it is red and fat it could be another sign of anaemia, as could angular stomatitis. Check state
of dentition - pigmentation of oral mucosa (Peutz-Jeghers syndrome), telangectasia, candidiasis.
Examine the neck for an enlarged left supraclavicular lymph node. A palpable enlarged supraclavicular
(Virchows) node is known as Troisiers Sign, may be a sign of malignancy. Virchows node drains the
thoracic duct and receives lymphatic drainage from the entire abdomen as well as the left thorax.
Therefore, enlargement of this node may suggest metastatic deposits from a malignancy in any of these
areas.
Examine the chest, in particular look for gynaecomastia in men and the presence of 5 or more spider
naevi. These are both stigma of liver pathology.
Inspect the abdomen and comment on any obvious abnormalities such as scars, masses and pulsations.
Also note if there is any abdominal dis tension/ascites. Look for distended veins, striae, Cullens/GreyTurners signs (pancreatitis), Sister Mary Joseph's nodule (widespread abdominal cancer)
/l\
I
\
Clinical Examination 65
Cardiovascular Examination
Inspect fingers for capillary refill time, peripheral cyanosis, osier's nodes (infective endocarditis) and
nicotine staining.
Inspect palms for palmar erythema,Janeway lesions and xanthomas.
Take the radial pulse, assess the rate and rhythm.At this point you should also check for a collapsing
pulse - a sign of aortic incompetence. Locate the radial pulse and place your palm over it, then raise the
arm above the patients head. A collapsing pulse will present as a knocking on your palm.
At this point you should say to the examiner that you would like to take the blood pressure. They will
usually tell you not to and give you the value.
Inspect the sclera for any signs of jaundice, anaemia and corneal arcus. You should also look for any
evidence of xanthelasma.
Whilst looking at the face, check for any malar facies, look in the mouth for any signs of anaemia such as
glossitis, check the colour of the tongue for any cyanosis, and around the mouth for any angular stomatitis
- another sign of anaemia.
Assess jugular venous pressure ( JVP), ask patient to turn their head to look away from you. Look across
the neck between the two heads of sternocleidomastoid for a pulsation then measure the JVP.
Examine the chest, or praecordium for any obvious pulsations, abnormalities or scars, remembering to
check the axillae as well.
Clinical Examination 67
Any skin changes such as pallor, change in colour (eg purple/black from haemostasis or brown from
haemosiderin deposition), varicose eczema or sites of previous ulcers, atrophic changes and hair loss.
Presence of any varicose veins - often seen best with the patient standing.
3. Palpation
Assess the skin temperature. Starting distally, feel with the back of your hand and compare each limb to
the other noting any difference.
Check capillary return by compressing the nail bed and then releasing it. Normal colour should return
within 2 seconds. If this is abnormal, perform Buergers Test. This involves raising the patients feet to 45.
In the presence of poor arterial supply, pallor rapidly develops. Following this, place the feet over the side
of the bed, cyanosis may then develop.
Any varicosities which you noted in the observation should now be palpated. If these are hard to the
touch, or painful when touched, it may suggest thrombophlebitis.
Palpate peripheral pulses. These are:
Carotid - only palpate one carotid at a time Radial - use the pad of three fingers Brachial - may use thumb
to palpate
Femoral - feel over the medial aspect of the inguinal ligament.
Popliteal - ask the patient to flex their knee to roughly 60 keeping their foot on the bed,
place both hands on the front of the knee and place your fingers in the popliteal space.
Posterior tibial - felt posterior to the medial malleolus of the tibia.
Dorsalis pedis -feel on the dorsum of the foot, lateral to the extensor tendon of the great toe. You should
compare these on both sides and comment on their strength.
Check for radio-femoral delay. Palpate both the radial and femoral pulses on one side of the body. The
pulsation should occur at the same time. Any delay may suggest coarctation of the aorta.
4. Auscultation : listen for femoral and abdominal aortic bruits
5. Special Tests
Allen Test : Ask the patient to make a tight fist and elevate the hand. Occlude the radial and ulnar
arteries with firm pressure. The hand is then opened. It should appear blanched (pallor can be observed at
the finger nails). Release either the Ulnar or radial artery pressure and the color should return in 7 seconds.
If the palm does not redden immediately, this suggests arterial insufficiency.
Straight Leg Raise and Refill Test (Buerger's Test) : Raise the leg 45 to 60 for 30 seconds until pallor of
the feet develops and observe empty veins. Sit the patient upright and observe the feet. In normal
patients, the feet quickly turn pink (within 10-15 seconds). If, pallor persists for more than 10- 15s or there
is development of a dusky cyanosis (rubor), this suggests of arterial insufficiency.
Test for incompetent Saphenous Vein : Ask the patient to stand and note the dilated varicose veins.
Compress the vein proximally with one hand and place the other hand 10-15 cm distally. Briskly compress
and decompress the distal site. Normally, the hand at the proximal site should feel no impulse, however
with varicose veins a transmitted pulse may be felt.
Trendelenburg Maneuver (Retrograde filling) : Ask the patient to lie down. Elevate the leg, and empty the
veins by massaging distal to proximal. Using a tourniquet, occlude the superficial veins in the upper thigh.
Ask the patient to stand. If the tourniquet prevents the veins from re-filling rapidly, the site of the
incompetent valve must be above this level i.e. at the sapheno-femoral junction. If the veins re-fill, the
communication must be lower down.
Observing the same protocol, proceed down the leg until the tourniquet controls re-filling. As necessary,
test:
above the knee - to assess the mid-thigh perforator
below the knee - to assess competence between the short saphenous vein and popliteal vein If re-filling
cannot be controlled, the communication is probably by one or more distal perforating veins.
Clinical Examination 69
Respiratory Examination
1. Steps before beginning examination
Introduce yourself : I am Dr.________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.
Wash/Sanitize hands
Explain to the patient what you are about to do and gain informed consent.
Look for medical equipment/therapies (e.g. inhalers, oxygen).
Verbalize the steps of the examination and your findings.
2. Inspection
General look of the patient. Check whether they are comfortable at rest, is patient tachypnoeic? Are they
using accessory muscles? Are there any obvious abnormalities of the chest? Check for any clues around
the bed such as inhalers, oxygen masks or cigarettes.
Inspect the hands, hot, pink peripheries may be a sign of carbon dioxide retention. Look for any signs of
clubbing, cyanosis, hypertrophic pulmonary osteoarthropathy, dupytren's contacture and nicotine staining.
Assess for carbon dioxide retention flap/salbutamol tremor.
Take the patients pulse. After you have taken the pulse it is advisable to keep your hands in the same
position and subtly count the patients respiration rate.
Inspect the face, ask the patient to stick out their tongue and note its colour - checking for cyanosis.
- Horner's sydrome (Pancoast tumour), plethora (polycythemia).
Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the left
supraclavicular node (Virchow's Node) as an enlarged node (Troisier's Sign) may suggest metastatic lung
cancer.
Examine the chest and back. Observe the chest for any deformities (barrel chest, kyphoscoliosis, pectus
excavatum, pectus carinatum), symmetry of expansion, dilated veins, intercostal recession.
3. Palpation
Palpate the chest. Feel between the heads of the two clavicles for the trachea, see if it is deviated.
Feel for chest expansion. Place your hands firmly on the chest wall with your thumbs meeting in the
midline. Ask the patient to take a deep breath in and note the distance your thumbs move apart. Normally
this should be at least 5 centimetres. Measure this at the top and bottom of the lungs as well as on the
back.
ComoMatton
Central
Dull
Increased
Bronchial
Occasional crackles
Pneumothorax
Away
Hyper-resonant
Decreased
Absent
Nil
Atelectasis
Towards lesion
Dull
Increased
Decreased
Nil
Fibrosis
Central
Resonant (normal)
Normal
Decreased if severe
Late inspiratory crackles
7. Finish by examining the lymph nodes in the head and neck. Start under the chin with the submental
nodes, move along to the submandibular then to the back of the head at the occipital nodes. Next palpate
the pre and post auricular nodes. Move down the cervical chain and onto the supraclavicular nodes.
Clinical Examination 71
Central Nervous System Examination
8) The Vagus nerve (CN X) provides motor supply to the pharynx. Asking the patient to speak gives a good
indication to the efficacy of the muscles. You should also observe the uvula before and during the patient
saying aah. Check that it lies centrally and does not deviate on movement.
9) The Accessory nerve (CN XI) gives motor supply to the sternocleidomastoid and trapezius muscles. To
test it, ask the patient to shrug their shoulders and turn their head against resistance.
10) The Hypoglossal nerve (CN XII) provides motor supply to the muscles of the tongue. Observe the
tongue for any signs of wasting or fasciculations. Then ask the patient to stick their tongue out. If the
tongue deviates to either side, it suggests a weakening of the muscles on that side.
3. Cerebellar Examination Gait:
Ask the patient to stand up. Observe the patient's posture and whether they are steady on their feet.
Ask the patient to walk, e.g. to the other side of the room, and back. If the patient normally uses a
walking aid, allow them to do so.
Observe the different gait components (heel strike, toe lift off). Is the gait shuffling / waddling /
scissoring/ swinging?
Observe the patients arm swing and take note how the patient turns around as this involves good
balance and co-ordination.
Ask the patient to walk heel-to-toe to assess balance.
Perform Rombergs test by asking the patient to stand unaided with his eyes closed. If the patient sways
or loses balance this test is positive. Stand near the patient in case he falls.
Co-ordination:
Look for a resting tremor in the hands.
Test tone in the arms (shoulder, elbow, wrist)
Test for dysdiadochokinesis by showing the patient to clap by alternating the palmar and dorsal surfaces
of the hand. Ask to do this as fast as possible and repeat the test with the other hand.
Perform the finger-to-nose test by placing your index finger about two feet from the patients face. Ask
him to touch the tip of his nose with his index finger then the tip of your finger. Ask him to do this as fast
as possible while you slowly move your finger. Repeat the test with the other hand.
Perform the heel-to-shin test. Have the patient lying down for this and get him to run the heel of one foot
down the shin of the other leg and then to bring the heel back up to the knee and start again. Repeat the
test with the other leg.
Clinical Examination 73
Upper Limb Neurological Examination
Finally, with their arm rested on their abdomen, locate the supinator tendon (C5/C6) as it crosses the
radius, place three fingers on it and hit the fingers. This should give the supinator reflex. If you struggle
with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex.
Clinical Examination 75
Lower Limb Neurological Examination
1. Steps before beginning examination
Introduce yourself : I am Dr._______, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and Ill stop the examination
right there.
Wash/Sanitize hands
Explain to the patient what you are about to do and gain informed consent.
Verbalize the steps of the examination and your findings.
Make sure patient is adequately exposed, use proper draping techniques
2. Inspection
Observe the patient's legs, look for any muscle wasting, fasciculations or asymmetry.
3. Tone
Start by examining the tone of the muscles. Roll the leg on the bed to see if it moves easily and pull up
on the knee to check its tone. Also check for ankle clonus by placing the patients leg turned outwards on
the bed, moving the ankle joint a few times to relax it and then sharply dorsiflexing it. Any further
movement of the joint may suggest clonus.
4. Power
Next assess the power of each of the muscle groups.
- Hip flexion (L1/L2) & Hip extension (L5/S1)
- Hip abduction (L2/L3) & Hip adduction (L2/L3)
- Knee flexion (L5/S1) & Knee extension (L3/L4)
- Ankle dorsiflexion (L4/L5) & Ankle plantar flexion (S1/S2)
- Big toe flexion (S1/S2)
5. Reflexes
Test the patient's reflexes. There are three reflexes in the lower limb - the knee reflex, the ankle jerk and
the plantar reflex - elicited by stroking up the lateral aspect of the plantar surface.
The knee reflex (L3/L4) is tested by placing the patient's leg flexed at roughly 60, taking the entire
weight of their leg with your arm and hitting the patellar tendon with the tendon hammer. It is vital to get
your patient to relax as much as possible and for you to take the entire weight of their leg.
The ankle jerk (S1/S2) is elicited by resting the patient's leg on the bed with their hip laterally rotated.
Pull the foot into dorsiflexion and hit the calcaneal tendon.
Finally, with their leg out straight and resting on the bed, run the end of the handle of the tendon
hammer along the outside of the foot. This gives the plantar reflex (Si). An abnormal reflex would see the
great toe extending. If you struggle with any of these reflexes, asking the patient to clench their teeth
should exaggerate the reflex.
7. Function is a very important part of any neurological examination as this is the area which will affect
peoples day to day lives the most. For the lower limb you should assess the patient's walking. Observe
their gait and check for any abnormalities. Whilst they are standing you should perform Romberg's test.
Ask the patient to stand with their feet apart and then close their eyes. Stand next to the patient in case
he falls. Any swaying may be suggestive of a posterior column pathology.
8. Finish by thanking the patient and ensuring they are comfortable and well covered.
Clinical Examination 77
Musculo-skeletal system : Spine/Back
1. Steps before beginning examination
Introduce yourself : aI am Dr.________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.
Wash/Sanitize hands
Explain to the patient what you are about to do and gain informed consent.
Ensure patient is adequately exposed.
Look for medical equipment/therapies
Show empathy.
Verbalize the steps of the examination and your findings.
2. Inspection
Ask for patients vitals
Observe patient : Is patient sitting comfortably? Gait? Position of comfort.
Observe the patient from behind :
- Pelvic and shoulder symmetry, palpate the pelvic brim to check for symmetry.
- Scoliosis
- Gibbus (dorsal spines abnormally prominent)
Observe patient from side :
- Kyphosis
- Increased lumbar lordosis
Check the spine for SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk),
D: Deformity, S: Skin changes/scars/bruising
3. Range of Motion
Flexion : In the standing position by asking the patient to touch the toes. Normal - 90 .The normal spine
should lengthen more than 5 cm in the thoracic area and more than 7.5 cm in the lumbar area on forward
flexion.
Extension : Stabilize the patient, ask the patient to bend backwards. Normal - 30.
Lateral flexion : ask the patient to slide their hand straight down the thigh, first on the right and then on
the left, keeping the hips straight.
Observe for restricted movement and loss of symmetry.
Test for facet joint disease : Ask patient to extend their back as far as possible and to rotate (pain
suggests facet joint pathology).
4. Palpation
Examine the back and palpate for areas of muscle spasm and tenderness (paraspinal muscles).
Palpate spinous processes with thumb for tenderness
Sacroiliac joints, sacro iliac dimples, ask for tenderness.
Clinical Examination 79
Hip Examination
wresoFGAfr
Antalgic ~ Trauma, OA Trendelenberg - weakness of hip adductors Festlnating - Parkinson's ds. High stepping - Polio, MS Scissor Spastic cerebral palsy
Stomping - Friedreich's ataxia, tabes dorsalis Spastc - Brain tumor, sturge Weber's, cerebral palsy
Clinical Examination 81
Knee Examination
1. Steps before beginning examination
Introduce yourself : I am Dr.________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.
Wash/Sanitize hands
Explain to the patient what you are about to do and gain informed consent.
Ensure patient is adequately exposed (up to above knees).
Look for medical equipment/therapies
Ask about knee locking, giving way and pain, show empathy.
Verbalize the steps of the examination and your findings.
2. Inspection
Gait : Ask the patient to walk for you. Observe any limp or obvious deformities such as scars or muscle
wasting. Check if the patient has a varus (bow-legged) or valgus (knock-knees) deformity.
Also observe from behind to see if there are any obvious popliteal swellings such as a Baker's cyst.
While the patient is lying on the bed, make a general observation. Look for symmetry, redness, muscle
wasting, scars, rashes or fixed flexion deformities.
3. Palpation
Check the temperature using the backs of your hands, comparing it with other parts of the leg.
Palpate the border of the patella for any tenderness, behind the knee for any swellings, along all of the
joint lines for tenderness and at the point of insertion of the patellar tendon. Finally, tap the patella to see
if there is any effusion deep to the patella.
Landmarks of the knee : Tibial tuberosity, patellar tendon, quadriceps tendon, medial and lateral femoral
condyles.
Peripatellar area : push patella medially and rub right underneath the medial facet of patella and look for
tenderness ( Patellar - femoral stress S).
Joint line tenderness : bend the knee 90, palpate medial and lateral joint line.
Patella apprehension test - Move patella around and observe patient's face for pain.
4. Range of Motion
Active flexion and extension of knee - Observe for restricted movement and for displacement of patella.
Passive flexion and extension of knee - feel for crepitus.
Straight leg raise - assessment of extensor apparatus.
Clinical Examination 83
Foot and Ankle Examination
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.
Wash/Sanitize hands
Explain to the patient what you are about to do and gain informed consent.
Ensure patient is adequately exposed (up to above knees).
Look for medical equipment/therapies
Ask if patient is able to bear weight, show empathy.
Verbalize the steps of the examination and your findings.
2. Inspection
Gait : watch the patient walk, observing for a normal heel strike, toe-off gait. Also look at the alignment
of the toes for any valgus or varus deformities. Assess ability to weight-bear on affected side.
While patient is standing check the foot arches checking for pes cavus (high arches) or pes planus (flat
feet).
Inspection of the foot with patient sitting and feet overhanging
- Check the foot and ankle for SEADS : S: Swelling, E: Erythema, ecchymosis,
A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/bruising.
- Check the symmetry, nails (psoriasis), skin, toe alignment, look for toe clawing, joint swelling and plantar
and dorsal calluses.
Finally you should look at the patients shoes, note any uneven wear on either sole and the presence of
any insoles.
3. Palpation of ankle/foot
Feel each foot for temperature, comparing it to the temperature of the rest of the leg.
Feel for distal pulses.
Squeeze over the metatarsophalangeal joints observing the patient's face for any pain.
Palpate over the midfoot, ankle and subtalar joint lines for any tenderness. Feel the Achilles tendon for
any thickening or swelling. Palpate medial and lateral malleoli for any tenderness.
4. Range of Motion
Assess all active and passive movements of the foot. These movements are inversion, eversion,
dorsiflexion and plantarflexion.
- Subtalar joint - inversion and eversion
- Ankle joint - dorsiflexion and plantar flexion
- Big toe - dorsiflexion and plantar flexion
- Mid-tarsal joints - which are tested by fixing the ankle with one foot and inverting and everting the
forefoot with the other.
5. Special tests
Ankle Anterior Drawer Test - assesses for lateral ankle sprain
Patient is seated, stabilize the tibia with one hand while grasping heel and pulling it anteriorly with the
other. Greater than 3 mm anterior movement may be significant. 1 cm is significant and indicates anterior
talofibular ligament rupture.
Positive Test - laxity in the ligament with exaggerated anterior translation
Talar Tilt Test - assesses integrity of the deltoid ligament/lateral ankle sprain
Patient is seated, stabilize the leg and foot while adducting and inverting the calcaneus apply a varus
force. The calcaneus is then abducted and everted applying a valgus force.
Positive Test - pain or laxity in the ligament
Thompsons Test - assesses for Achilles' tendon rupture
Patient is prone, squeeze the gastrocnemius and soleus muscles while noting any movement at the ankle
and foot
Positive Test - no movement or plantarflexion at all indicates a 3rd degree strain of the Achilles' tendon
Plantar Fasciitis Test - assesses for inflammation of the plantar fascia
Patient is supine, dorsiflex the ankle and extends all toes then press in the medial border of the plantar
fascia
Positive Test - pain is consistent with plantar fasciitis Ottawa Ankle rules
For taking ankle series x-rays(AP and lateral ankle)
X-ray if there is pain over the malleolar zone AND tenderness on palpation of the medial/lateral malleolar
tip and posterior aspect of medial/lateral malleolus OR
Patient unable to bear weight immediately and in ER.
For foot series (AP and Lateral foot)
X-ray if there is pain in midfoot zone AND bony tenderness over the navicular or base of 5th metatarsal
OR
Unable to bear weight immediately and in ER
Clinical Examination 85
Shoulder Examination
1. Steps before beginning examination
Introduce yourself : I am Dr.________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.
Wash/Sanitize hands
Explain to the patient what you are about to do and gain informed consent.
Look for medical equipment/therapies, ensure patient is adequately exposed.
Ask which shoulder is painful. Verbalize the steps of the examination and your findings.
2. Inspection
Start by exposing the joint and observe the shoulder joint looking from the back, side and front for any
scars, deformities or muscle wasting (SEADS). Also compare both sides for symmetry.
With the patient standing, ask the patient to place their hands behind their head and behind their back
and observe for and deformities.
3. Palpation
Feel over the joint and its surrounding areas for the temperature of the joint as raised temperature may
suggest inflammation or infection in the joint.
Systematically feel along both sides of the bony shoulder girdle. Start at the sternoclavicular joint, work
along the clavicle to the acromioclavicular joint
Feel the acromion and then around the spine of the scapula.
Feel the anterior and posterior joint lines of the glenohumeral joint and finally the muscles around the
joint for any tenderness.
4. Range of Motion
The movements of the joint should start being performed actively.
Ask the patient to bring their arm forward (flexion), bend their arm at the elbow and push backwards
(extension),
Bring their arm out to the side and up above their head (abduction). When testing adduction perform the
scarf test (The scarf test is performed with the elbow flexed to 90 degrees, placing the patient's hand on
their opposite shoulder and pushing back, again look for any discomfort. )
Rotation
- Internal rotation : Ask the patient to place hands in the small of their back, and slide them up the back as
far as possible.
- External rotation : Ask patient to rotate their arms outwards, keeping the elbows flexed and by the side of
the body.
Once all of these movements have been performed actively, you should perform them passively and feel
for any crepitus whilst moving the joints.
5. Special Tests
Tests for Rotator Cuff
i. Supraspinatus
Empty Can Test ( tests integrity of Supraspinatus) : The patient stands with arms extended at the elbows
and abducted in the scapular plane and with thumbs pointed to the floor. The examiner applies downward
pressure to the arms and the patient attempts to resist.
Positive test : Pain, muscle weakness or both.
Apley's Scratch Test- Reach over shoulder to "scratch" between scapula. Measure to which vertebrae
thumb can reach.
ii. Infraspinatus
External Rotation Lag Sign : The elbow is passively flexed to 90 degrees, and the shoulder is held at
20 degrees abduction (in the scapular plane) and near maximal external rotation by the examiner. The
patient is then asked to actively maintain the position of external rotation in abduction as the examiner
releases the wrist while maintaining support of the limb at the elbow. The sign is positive when a lag, or
angular drop occurs. The magnitude of the lag is recorded to the nearest 5 degrees.
iii. Subscapularis
Gerber Lift-OfFTest : With the patients hand on the small of the back, the arm is extended and internally
rotated. The examiner then passively lifts the hand off the small of the back, placing the arm in maximal
internal rotation. The examiner then releases the hand. If the hand falls onto the back because the
subscapularis is unable to maintain internal rotation, the test result is positive. Patients with subscapularis
tears have an increase in passive external rotation and a weakened ability to resist internal rotation.
Tests for Shoulder Instability
Apprehension Sign for Anterior Instability : The test is performed by abducting the shoulder to 90
degrees, and then slowly externally rotating the shoulder toward 90 degrees. A patient with anteriorinferior instability will usually become "apprehensive" either verbally or with distressing facial expressions.
Tests for Subacromial Impingement
Neer Impingement Sign : Place one hand on the posterior aspect of the scapula to stabilize the
shoulder girdle, and, with the other hand, take the patient's internally rotated arm by the wrist, and place
it in full forward flexion.If there is impingement, the patient will report pain in the range of 70 degrees to
120 degrees of forward flexion as the rotator cuff comes into contact with the rigid coracoacromial arch.
Hawkins Impingement Sign : The examiner places the patient's arm in 90 degrees of forward flexion
and forcefully internally rotates the arm, bringing the greater tuberosity in contact with the lateral
acromion. A positive result is indicated if pain is reproduced during the forced internal rotation.
Tests for Long Head of the Biceps
Speed's Maneuver : The patient's elbow is flexed 20 degrees to 30 degrees with the forearm in
supination and the arm in about 60 degrees of flexion. The examiner resists forward flexion of the arm
while palpating the patient's biceps tendon over the anterior aspect of the shoulder.
Yergason test : The patient's elbow is flexed to 90 degrees with the thumb up. Forearm is in neutral.
The examiner grasps the wrist, resisting attempts by the patient to actively supinate the forearm and flex
the elbow. Pain suggests biceps tendonitis.
Clinical Examination 87
Elbow Examination
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.
Wash/Sanitize hands
Explain to the patient what you are about to do and gain informed consent.
Look for medical equipment/therapies
Verbalize the steps of the examination and your findings.
2. Inspection
Inspect hands :
- Skin (rashes, Gottron's patches, nodules, Raynaud's phenomenon, sclerodactyly, scars, skin atrophy)
- Nails (pitting, onycholysis, splinter haemorrhages, clubbing)
- Muscles (swelling, wasting)
- Joints (swellings, subluxation / deviation of wrist, swan neck / Boutoniere's deformity,
Heberden's/Bouchard's nodes, Z deformity of thumb)
- Inspect palm (palmar erythema, pallor, cyanosis), muscle wasting.
Inspect elbows :
- Psoriatic skin lesions
- Rheumatoid nodules
- Scars
3. Palpation
Assess the temperature over the joint areas and compare these with the temperature of the forearm.
Start proximally and work towards the fingers, feeling the radial pulses and the wrist joints. Then feel the
muscle bulk in the thenar and hypothenar eminences. In the palms, feel for any tendon thickening and
assess the sensation over the relevant areas supplied by the radial, ulnar and median nerves.
Squeeze over the row of metacarpophalangeal joints whilst watching the patient's face for any
discomfort.
Bi-manually palpate MCP and interphalangeal joints.
Clinical Examination 89
4. Range of Motion
Ask the patient to perform the following movements in the sequence mentioned below and observe for
range of movement :
- Make a fist
- Pronate wrist
- Extend little finger (extensor digiti minimi is usually the first tendon to rupture in rheuatoid arthritis)
- Extend all fingers
Assess function
- Pinch grip
- Opposition (touch thumb to each finger)
- Power grip (ask patient to squeeze your fingers)
- Froment's test (for ulnar nerve palsy). In this test the patient attempts to grip a paper with thumb and
index finger while the examiner tries to pull the paper out of the patient's grip.
- Ask patient to write something / undo a button.
Assess power
- Wrist extension (radial nerve)
- Thumb abduction (median nerve)
- Finger abduction (ulnar nerve)
5. Neurovascular Examination
Nerve
Sensation
Motor
Median
Lateral portions of the pulp of the index and middle fingers
Resisted palmar abduction of the thumb
Ulnar
Lateral pulp areas of the little finger
Abduction of the fingers against resistance
Radial
Web space between the thumb and index finger (anatomical snuff box)
Wrist extension
6. Special Tests
Phalen's test : Forced flexion of the wrist, either against the other hand or by the examiner for 60
seconds will recreate the symptoms of carpal tunnel syndrome.
Finkelsteins test is used to diagnose DeQuervain's tenosynovitis. Patient is told to flex the thumb and
clench the fist over the thumb followed by ulnar deviation. If there is an increased pain in the radial styloid
process and along the length of the extensor pollicis brevis and abductor pollicis longus tendons, then the
test is positive for De Quervains syndrome.
Tinel's sign : Use the index finger to tap over the carpal tunnel at the wrist. A positive test results when
the tapping causes tingling or paresthesia in the area of the median nerve distribution, which includes the
thumb, index finger, and middle and lateral half of the ring finger. A positive Tinel's sign at the wrist
indicates carpal tunnel syndrome.
Introduce yourself : I am Dr._______, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.
Wash/Sanitize hands
Explain to the patient what you are about to do and gain informed consent.
Verbalize the steps of the examination and your findings. Ask which side the problem is.
Make sure patient is adequately exposed, use proper draping techniques
1. General Inspection (with patient sitting on side of bed)
Inspect with :
- Patient's arm by their sides.
- Patients arms behind their head (tenses skin)
- Patient's hands on their hips (tenses pectoralis major)
These manoeuvers test forT4 disease - invasion of chest wall / skin. Inspect for :
- Obvious masses
- Scars
- Radiotherapy tattoos
- Skin changes
- Peau d'orange
- Dimpling
- Nipple retraction
- Paget's disease.
2. Inspection (with patient lying down)
- Breasts size, symmetry and contour.
- Areola pigmentation, nipple pigmentation, shape, ulceration and discharge.
- Skin color, thckening, venous pattern and edema.
3. Palpate
- Palpate normal breast followed by abnormal breast.
- Palpate all quadrants, nipple and axillary tail of each breast.
- Describe any masses : position, size shape, mobility, number, tenderness, consistency.
- Palpate axillary, supraclavicular and infraclavicular lymph nodes.
4. Auscultate lungs.
Clinical Examination 91
Thyroid Examination
1. Steps before beginning examination
Introduce yourself : I am Dr._______, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.
Wash/Sanitize hands
Explain to the patient what you are about to do and gain informed consent.
Ensure patient is adequately exposed.
Look for medical equipment/therapies
Show empathy.
Verbalize the steps of the examination and your findings.
2. Inspection
Ask for patients vitals.
Observe patient : Is patient anxious? Weight gain/loss? Note hoarseness of voice.
Feel pulse - rate/rhythm/volume
Face : Facial expression ( dull in hypothyroidism)
Periorbital myxedema Loss of l/3rd of eyebrows Hair - texture/alopecia
Exophthalmos (look from behind patient), lid lag
Ophthalmoplegia (ask patient to follow your finger then ask for diplopia)
Clinical Examination 93
Mini Mental State Examination
1. ORIENTATION
Maximum score = 10
What is today's date?
1
What is the year?
1
What is the month?
1
What is the day today?
1
Can you tell me what season it is?
1
Can you also tell me the name of the location we are in? (Hospital/clinic)
1
What floor are we on?
1
What city are we in?
1
What country are we in?
1
What state are we in?
1
II. IMMEDIATE RECALL
Maximum score = 3
Ask the patient if you may test his/her memory. Say the words "ball" , "flag" , "tree" clearly and slowly. Then ask the patient to
repeat the words. Check for each correct response. The first repetition determines the score. If the patient does not repeat all
three correctly, keep saying them up to six tries until the patient can repeat them.
Ball
1
Flag
1
Tree
1
Number of Trials :__
III. ATTENTION AND CALCULATION
A. Counting Backwards Test
Record each response
Maximum score = 5
Ask the patient to begin with 100 and count backwards by 7. Record each response. Check one box at right for each correct
response. The score is the number of correct subtractions.
93
1
86
1
79
1
72
1
65
1
B. Spelling Backwards Test
Ask the patient to spell the word "WORLD" backwards. Record each response. Use the instructions to determine which are
correct responses, and check one box at right for each correct response.
D
1
L
1
R
1
0
1
W
1
C. Final Score
Compare the scores of the Counting Backwards and Spelling Backwards tests. Write the greater of the two scores in the box
labeled FINAL SCORE at right, and use it in deriving the TOTAL SCORE.
Final Score :
(Max of 5 or Greater of the two scores)
IV. RECALL
Maximum score = 3
Ask the patient to recall the three words you previously asked him/her to remember. Check the Box at right for each correct
response.
Ball
1
Flag
1
Tree
1
V. LANGUAGE
Maximum score = 9
Naming
Watch
1
Show the patient a wrist watch and ask him/her what it is. Repeat for a pencil.
Pencil
1
Repetition
Ask the patient to repeat "No ifs, ands, or buts."
Correct repetition
1
Three - Stage Command
Establish the patient's dominant hand. Give the patient a sheet of blank paper and say, 'Take the paper in your right/left hand,
fold it in half and put it on the floor."
Takes paper in hand
1
Folds paper in half
1
Puts paper on the floor
1
Reading
Hold up the card that reads, "Close your eyes." So the patient can see it clearly. Ask him/her to read it and do what it says.
Check the box at right only if he/she actually closes his/her eyes.
Closes eyes
1
Writing
Give the patient a sheet of blank paper and ask him/her to write a sentence. It is to be written spontaneously. If the sentence
contains a patient and a verb, and is sensible, check the box at right. Correct grammar and punctuation are not necessary.
Writes sentence
1
Copying
Show the patient the drawing of the intersecting pentagons. Ask him/her to draw the pentagons (about one inch each side) on
the paper provided. If ten angles are present and two intersect, check the box at right. Ignore tremor and rotation.
Copies pentagons
1
Clinical Examination 95
""i
DERIVING THE TOTAL SCORE
Add the number of correct responses. The maximux is 30.
23-30
Normal
23-19
Borderline
Less than 19
Impaired
Clinical Cases
This is a blank page
U (You) your daily activities : Does it interfere in your day to day activities? Does it change with your daily
activities like posture, rest, eating, exertion?
V (Deja vu) : Has it happened before? When? What happened then? What medication?
Aggravating factors : What makes it worse?
Alleviating factors : What make it better?
Associated symptoms : Have you noticed anything that occurs with it?
Al : Associated constitutional symptoms like fever, shortness of breath, cough, nausea, vomiting,
diarrhea, headache, fatigue (FSC NVD HF)
A2 : Associated symptoms to particular system
Respiratory : Chest pain, shortness of breath, cough, sputum, wheezing, runny nose, post nasal drip,
contact with ill person, night sweats, questions for pulmonary embolism (leg pain, long travel, surgery and
OCP use in females)
CVS : chest pain, orthopnea, paroxysmal nocturnal dyspnea, palpitations, tachycardia.
GIT : pain in abdomen, stool, bowel movements, vomiting, jaundice, blood in stools, diet, travel.
Neurology : headache, loss of consciousness, weakness, paresthesias Higher Mental Function : orientation,
memory, consciousness.
Motor : weakness of limbs.
Sensory : tingling sensation.
Cerebellum : gait, balance.
Cranial Nerves : speech, swallowing, vision, hearing.
PAM HUGS FOSS
Ok, Mr./Miss_____, Now I need to ask you about your health in general. Is that okay with you?
Past Medical History : What other medical problems do you have? (Diabetes/Hypertension/Asthma /
Cancer?)
Allergies : Do you have any allergies? Are you allergic to any drugs?
Tammy Robbins, a 48 years old lady presented with heart racing and chest discomfort for the past 3 days.
Take a focused history and perform focused physical examination.
Vitals: BP - 90/70 mm Hg, HR - 146/min, irregular, RR - 12/min,Temp - 37.5C
Clinical Info: Ms Tammy Robbins is a known hypertensive with CAD for the past 10 years, who presented
with sudden onset of palpitations and chest discomfort for the past 3 days. Her symptoms are worsening
for the past 24 hours. She has dyspnea. She has dizziness for the past 12 hours. Pedal edema is 2 +. She
had 2 vessel angioplasty done 5 years ago. ECG shows absent P waves with irregular narrow QRS
complexes. Bilateral basal rales present on lung auscultation.
Clinical Case : Atrial Fibrillation (examination on page 65)
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of palpitations?
Simon Charles, a 20 years old male presented to your clinic with shortness of breath for the past 24 hours.
Take a focused history and perform focused physical examination.
Vitals: BP - 110/80 mm Hg, HR - 110/min, RR - 22/min,Temp - 37.5C.
Clinical Info: Mr Simon Charles has a h/o of Asthma since the past 10 years. He recently cleaned his
basement 1 day ago and his asthma symptoms exacerbated. He is having wheezing, chest tightness,cough
and SOB. He is currently on inhalers with no night symptoms. On examination, he has dyspnea and
wheezing present in all lung fields. He has mild exacerbation of his symptoms and needs only outpatient
treatment. Clinical Case : Asthma (examination on page 69)
HOPI
OCD PQRST UV + AAA How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Do you wake up in night with shortness of breath?
Larry Edwards, a 55 years old man presented with blood in sputum and shortness of breath for the past 5
days. Take a focused nistory and perform focused physical examination.
Vitals: BP - 160/110 mm Hg, HR - 96/min, RR - 18/min,Temp - 37.5C.
Clinical Info: Mr Larry Edwards is a known hypertensive who presented with shortness of breath and blood
in sputum for 5 days. It is gradual in onset. He has chest pain also. No fever or recurrent pneumonia. He is
non compliant with his medications. He is on Losartan, Aspirin, Atorvas, multi vitamins. He has not taken
his anti-hypertensives for 4 weeks. Has paroxysmal nocturnal dyspnea and orthopnea.
Clinical Case : Congestive Heart Failure (examination on page 65)
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of blood in sputum?
Amount / color of blood of sputum?
Any of shortness of breath?
Present at rest or with exertion?
H/o orthopnea?
H/o paroxysmal nocturnal dyspnea?
Any chest pain/palpitations?
Type of pain - sharp or dull?
Does the pain radiate or shoot anywhere?
Severity of pain on a scale of 1-10.
Do your symptoms change with time??
H/o fever/cough/sore throat/rash?
Any chills/nignt sweats?
Any swelling of face or feet?
Any change in weight/appetite?
Any bruises on the body?
Any trauma recendy?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Compliance with medications?
Are you allergic to any medications?
Any surgeries in the past?
Past h/o recurrent infections?
Family and Social History
Do you smoke? Duration & frequency.
Do you consume alcohol? Duration & frequency.
Do you use recreational drugs? TRAPPED.
Any family history of cancers/ medical illnesses?
Any family history of heart disease?
Differential Diagnosis
Management
Pulmonary Edema due to CHF.
Symptomatic treatment.
Pulmonary embolism.
Admit in cardiac care unit.
Bronchiectasis.
Inj Lasix 40 mg IV stat.
Beta blockers & ACE inhibitors.
Drug induced coagulopathy.
Pneumonia.
Inj Morphine 2-4 mg IV.
Investigations
Nasal oxygen.
Sublingual Nitroglycerines.
CBC, electrolytes, glucose.
Position - 45 degree elevation of head end.
LFT, RFT.
PT, PTT, INR.
12 lead ECG.
Echocardiogram.
Chest X Ray.
Jack Allen, a 65 years old man presented with sudden onset of right arm weakness 4 hours ago. Take a
focused history and perform focused physical examination.
Vitals: BP - 160/90 mm Hg, HR - 96/min, RR - 12/min,Temp - 37.5C.
Clinical Info: Mr Jack Allen presented with sudden onset of right arm weakness with numbness and
paresthesias 4 hours ago. He has slurring of speech, blurring ofvision and mild headache. He has no
nausea,vomiting or head trauma. No weakness of lower limbs or left arm. No incontinence. He is
hypertensive for the past 10 years and non compliant to medications.
Clinical Case : Cerebrovascular Attack (examination on page 71)
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of weakness?
Where is the weakness located?
Is there any associated pain in the arm?
Any numbness/tingling/paresthesias?
Any limitations in right arm movements?
Any abnormal position of right arm?
Do your symptoms change with time?
Any changes in vision?
Any changes in speech?
Any difficulty swallowing/drooling of saliva?
Any headache/trauma?
Any weakness of left arm or lower limbs?
Any seizures?
Any changes in facial expression?
H/o fever/cough/sore throat/rash?
Any chest pain/shortness of breath?
Any changes in bowel & urinary habits?
Past History
Do you have diabetes or hypertension?
Are you on any medications/compliance?
Are you allergic to any medications?
Any surgeries in the past?
Family and Social Histoiy
Do you smoke? Duration & frequency.
Do you consume alcohol? Duration & frequency.
Do you use recreational drugs? TRAPPED.
Any family history of cancers/ medical illnesses?
Differential Diagnosis
Management
Cerebrovascular Attack.
Admit urgently.
Transient Ischaemic Attack.
Urgent neurological consult.
Sub Arachnoid Hemorrhage.
Neurovitals q 1 hourly.
Investigations
Nasal oxygen.
Tab Aspirin 325 mg PO OD.
CBC, ESR, Glucose.
Blood pressure control.
Lipid profile, RFT.
PT, PTT, INR.
Thrombolysis to be done only if presented
within 3 hours of onset of symptoms.
ECG.
CT MRI Head.
Echo, Carotid doppler.
Duration of dizziness?
Any relieving factors?
Any aggravating factors?
Any episode of fainting?
Any weakness/tingling/paresthesias of limbs?
Any chest pain/palpitations?
Any shortness of breath?
Any visual changes/headache?
Any hearing loss/ear discharge?
Any excessive sweating?
Any fever/cough/vomiting?
Any abdominal pain/loss of appetite?
Any changes in bowel/urinary habits?
Any swelling of ankles?
Do your symptoms vary with change in head position?
List of current medications & compliance?
Any changes in medications & dosages?
Any recent trauma?
Past History
Do you have diabetes or hypertension?
Are you allergic to any medications?
Any surgeries in the past?
Past h/o recurrent infections?
Family and Social History
Do you smoke? Duration & frequency.
Do you consume alcohol? Duration oc frequency.
Do you use recreational drugs? TRAPPED.
Any family history of cancers/ medical illnesses?
Differential Diagnosis
Digoxin toxicity.
Arrhythmia.
TIA.
Anxiety disorder.
Medication induced bradycardia.
Investigations
Serum Digoxin level.
CBC, electrolytes, RFT.
INR/PTT, glucose.
ECG, 24 hour Holter monitor.
Echocardiogram,Carotid Doppler.
Management
Admit in cardiac care unit.
Stop Digoxin.
Start Digibind in case of massive overdose or refractory toxicity.
External Pacemaker.
Jason Hardinge, a 26 years old university student wants to discuss confidential issues with a doctor. Take
focused history and address his concerns.
Vitals: BP - 120/88 mm Hg, HR - 88/min, RR - 12/min,Temp - 37.5C
Clinical Info: Mr Jason Hardinge is having difficulty in maintaining erection duringintercourse for the past 4
months. He is currently in a monogamous relationship with his girlfriend. He is on raroxetin for his mood
disorder for 6 months. No other medical illnesses. Girlfriend is very understanding. He has no morning or
night tumescence. Has no erection with self stimulation. He is very anxious about this issue.
Clinical Case : Impotence
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of impotence?
Course & frequency of impotence?
Description of the problem: no erection at all, cannot sustain erection, ejaculate too quickly to satisfy
partner?
Cannot achieve orgasm or orgasm without ejaculation?
Any retrograde ejaculation?
Circumstances under which impotence occurs only with certain partners, only at certain times or
locations, what percentage of the time?
Srson with similar symptoms. O/E: Febrile, Brudzinski's and Kernig's sign are positive, linical Case :
Meningitis (examination on page 71)
HOPI
Nasal oxygen.
Panic Attack.
Tab Aspirin 160-325 mg chewable stat. Inj Morphine 2-4 mg IV stat & pm.
Investigations
Bed rest.
Adam Sawyer, a 18 years old male presented with fever, cough for 1 week along with shortness of breath.
Take a focused history and perform focused physical examination.
Vitals: BP - 110/70 mm Hg, HR - 96/min, RR - 20/min,Temp - 38.5C.
Clinical Info: Adam Sawyer has fever and expectorant cough for the past 1 week. He has wheezing and
shortness of breath for 2 aays. On auscultation of chest, there is decreased breath sounds on left side with
rales present.
Clinical Case : Pneumonia (examination on page 69)
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Jacob Sandler, a 50 years old man presented with hemoptysis and right sided calf swelling for the past 2
days. He had knee replacement surgery 1 week ago. Take a focused history and perform focused
examination. Vitals: BP - 140/80 mm Hg, HR - 110/min, RR - 18/min,Temp - 37.5C.
Clinical Info: Mr Jacob Sandler had a right knee replacement 1 week ago. He now presented with 2
episodes of hemoptysis and right calf swelling witn tenderness. He has no fever or infection of surgical
wound. Homans sign is positive with ECG showing S1Q3T3 pattern.
Clinical Case : Pulmonary Embolism (examination on page 69)
HOPI
OCD PQRST UV + AAA How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of blood in sputum?
Amount / color of blood of sputum?
Onset of shortness of breath/chest pain? Present at rest or with exertion?
H/o orthopnea?
H/o paroxysmal nocturnal dyspnea? Duration of leg swelling?
Where is the leg swelling located?
Any leg pain associated with swelling?
Type of pain - sharp or dull pain?
Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10.
Any pain during rest?
Any pain in the night time?
Any skin discoloration of legs/nail changes? Any skin ulceration of legs?
Any fever/cough/cold?
Any headache/dizziness?
Any weakness/muscle pain?
Any prolonged immobilization?
Any pain/discharge from the wound?
Any pre-op or intra-op complications?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Are you allergic to any medications?
Any surgeries in the past?
Past h/o recurrent infections?
Family and Social Histoiy
Do you smoke? Duration & frequency.
Do you consume alcohol? Duration &, frequency.
Do you use recreational drugs? TRAPPED.
Any family history of cancers/ medical illnesses?
Differential Diagnosis
Management
Pulmonary embolism.
Admit in Intensive care unit.
Deep Vein Thrombosis.
Elevate head end to 45 degree.
Pulmonary edema due to CHF
Nasal oxygen.
Myocardial infarction.
Give chewable ASA 160-325 mg
immediately.
Investigations
Secure IV access, bolus IV Lasix 40 mg.
CBC, RFT.
Ventolin if wheezes are heard.
Electrolytes, glucose.
Serial CK-MB and Troponin q8h X 3.
Sublingual nitro spray, if blood pressure is
adequate.
Inj Morphine 1 mg IV.
Arterial blood gases.
D-dimer, PT, PTT, INR, factor assay.
Inj Heparin 7500 UIV bolus, then infuse at 1200 U/h, then switch to warfarin.
ECG, Echocardiogram.
Chest X Ray.
Continue anticoagulation for 3 months.
PET Scan or VQscan.
Doppler of lower limbs.
Post-ictal state (decrease in level of consciousness, headache, sensory phenomena, tongue soreness, limb
pains, Todd's paralysis - hemiplegia)
Degree of control achieved with medications.
Was a CT scan done when seizures were first diagnosed?
Number and description of recent seizures. Are they different from previous seizures?
Is the patient having any new symptoms like headache, vomiting, new neurological deficits?
Side effects of antiepileptics: drowsiness, poor concentration, poor performance in school, ataxias,
peripheral neuropathy, acne, nystagmus, dysarthria, hypertrichosis, gingival hypertrophy.
Past History
Do you have diabetes or hypertension?
Any surgeries in the past?
Past h/o recurrent infections?
Family and Social History
Do you smoke? Duration & frequency.
Do you consume alcohol? Duration & frequency.
Do you use recreational drugs? TRAPPED.
Any family history of cancers/ medical illnesses?
Diagnosis
Management
Seizure Disorder
Discuss compliance of medications.
Regular follow up.
Investigations
Avoid alcohol consumption/smoking.
CBC, electrolytes.
Avoid recreational drugs.
Inform to the patient Ministry of
Serum drug levels.
EEG.
Transportation regulations require patient to be seizure free for 1 year or more.
Notify Ministry of Transportation as required by law.
Jason Scott, a 30 years old manjpresented with yellowish discoloration of eyes and skin for the past 1
week. Take a focused history and perform focused physical examination.
Vitals: BP - 120/88 mm Hg, HR - 96/min, RR - 12/min,Temp - 38.0C.
Clinical Info: Mr Jason Scott presented with yellowish discoloration of eves and skin for the past 1 week. It
has progressed gradually. He has right upper quadrant abdominal pain. He has loss of appetite, malaise,
nausea and vomiting. His urine is high colored and stool is pale colored. He has low graae fever. He has
few tattoos on his body along with body piercing. He is a chronic alcoholic, smoker and fv drug user for the
past 10 years.
Clinical Case : Viral Hepatitis (examination on page 63)
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of yellowish discoloration?
Any fever/chills/night sweats?
Any abdominal pain/location/duration?
Any nausea/vomiting?
Any pruritus/rash?
Any bruises/spontaneous bleeding?
Any loss of appetite/weight?
Any bowel complaints/color of stools?
Any urinary complaints/color of urine?
Any fatigue/malaise?
Any confusion/irritability/seizures?
Any aggravating factors?
Any relieving factors?
Any contact with sick person?
Any recent travel?
Past History
Do you have medical illnesses?
Are you on any medications?
Are you allergic to any medications?
Any surgeries/dental procedures in the past?
Past h/o recurrent infections?
Family and Social History
Do you smoke? Duration & frequency.
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Lisa Raymond, a 28 years old lady presented to the ER with lower abdominal pain on the left side for the
past 12 hours. Take a focused history and perform a focused examination (Page 63).
Vitals: BP - 100/70 mm Hg. HR - 98/min. RR - 16/min.Temp - 37.5C
Clinical Info: Ms Lisa Raymond, presented with h/o left side lower abdominal pain for 12 hours with mild
spotting. LMP: 2 months ago. Bi-manual exam has cervical motion tenderness & left adnexal fullness.
Clinical Case : Ectopic Pregnancy
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Since how long have you noticed the pain?
Where is the pain located?
Sharp or dull pain?
Does the pain radiate or shoot anywhere?
Severity of pain on a scale of 1-10.
Type Sc amount of bleeding per vagina?
Do your symptoms change with time?
H/o fever/nausea/vomiting?
Any changes in bowel & urinary habits?
Date of last menstrual period?
Any trauma recendy?
When was your last meal?
Blood group.
Gynecological History
Age of onset of menses
Regular/irregular?
Duration of menses?
Amount of bleeding/passage of clots?
Any dysmenorrhea?
Obstetrical History
Do you have children? If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple
births, complications in pregnancy.
H/o ectopic pregnancy?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Are you allergic to any medications?
Any surgeries in the past?
Past h/o sexually transmitted infections?
When was your last PAP test & results?
Family and Social History
Do you smoke or consume alcohol?
Do you use recreational drugs?
Currendy in a relationship? How long?
Sexual orientation?
Are you at risk of abuse?
Any family history of cancers?
Differential Diagnosis
Ectopic pregnancy.
Threatened abortion.
Pelvic Inflammatory Disease.
Ovarian torsion.
Endometriosis.
Investigations
CBC.
Blood group, type and cross match.
Beta HCG
Electrolytes, Renal function tests.
Pelvic ultrasound.
Management
Admit
IVF
Urgent gynecology consult
Rhogam if needea.
Medical treatment:
Inj Methotrexate 50 mg/m2 given IM as stat dose.
Serial Beta HCG till levels drop to <1.
Contraception advice till completion of treatment.
Surgical treatment : Laparoscopy/ Laparotomy.
Clinical Info: Ms Alyssa Jones is a 18 years old student with no significant history of medical illnesses. She
is in an active sexual relationship for the past 4 months. Had one episode of STI 6 months ago. LMP was 1
week ago. No family history of cancers. Currently using barrier contraception.
Clinical Case : OCP Counseling
HOPI
When was the last menstrual period?
Do you get headaches often?
Do you nave any bleeding disorders?
Any thromboembolic events?
Any liver disease?
Any uncontrolled high blood pressure?
Any heart disease?
Any mass in the breast?
Any abnormal vaginal bleeding?
Any history of sexually transmitted infections?
Any abnormal PAP results?
When was the last PAP done?
Sexual orientation?
Currently in a relationship? How long?
Number of sexual partners?
Do you practice safe sex?
Do you smoke or consume alcohol?
Do you use recreational drugs?
Are you on any medications?
Are you allergic to any medications?
Gynecological History
Age of onset of menses
Regular/irregular?
Duration of menses?
Amount of bleeding/passage of clots?
Any dysmenorrhea?
Current contraception use?
Obstetrical History
Have you been pregnant before?
If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple births, complications in
pregnancy.
H/o ectopic pregnancy?
Past History
Any hospitalizations?
Any surgeries in the past?
Family History
Family history of hypertension/diabetes?
Family history of breast/ovarian/endometrial cancers?
Family history of bleeding disorders?
Investigations
PAP test & complete physical.
Vaginal & Cervical swabs, culture/sensitivity.
Benefits of OCP
Prevention of unwanted pregnancy.
Reduced blood loss.
Decreased dysmenorrhea.
Cycle regularization.
Decreased risk of breast/ovarian/endometrial cancers.
Decreased acne.
Decreased osteoporosis.
Decreased PMS symptoms.
Reversible contraception.
Management
Tab Yasmin one tab OD for 28 days.
Begin pill on first Sunday after onset of Menses
If Menses start on Sunday, then start pill Day 1
Use barrier Contraception for Days 1-7 If pill started after Day 5:
OCP may not suppress Ovulation for first cycle
Use barrier Contraception for first month.
Follow up 6 weeks after the start of the pill.
Maria Santosa, a 28 years old lady presented with lower abdominal pain, dyspareunia and vaginal
discharge for 1 week. Take a focused history and perform focused examination.
Vitals: BP - 120/80 mm Hg. HR - 90/min. RR - 12/min.Temp - 38.5C
Clinical Info: Ms Maria Santosa presented with h/o lower abdominal pain for 1 week with dyspareunia and
foul smelling vaginal discharge. She has mild fever for 2 days. H/o unprotected intercourse +. H/o of past
infection 3 months ago. LMr: 1 week ago. Bi-manual exam has cervical motion tenderness & right adnexal
fullness.
Clinical Case : Pelvic Inflammatory Disease (examination on page 63)
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Since how long have you noticed the pain?
Where is the pain located?
Sharp or dull pain?
Does the pain radiate or shoot anywhere?
Severity of pain on a scale of 1-10.
H/o painful intercourse?
Type & amount of vaginal discharge?
Do your symptoms change with time?
H/o fever/cough/rash/vomiting?
Any chills/night sweats?
Any changes in bowel & urinary habits?
Any spotting per vagina?
Date of last menstrual period?
Do you practice safe sex?
Number of sexual partners?
Gynecological History
Age of onset of menses
Regular/irregular?
Duration of menses?
Amount of bleeding/passage of clots?
Any dysmenorrhea? lntra uterine devices?
Obstetrical History
Do you have children? If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple
births, complications in pregnancy.
H/o ectopic pregnancy?
Past History
Do you have diabetes or hypertension?
Did you suffer from any diseases in the past like tuberculosis?
Are you on any medications?
Are you allergic to any medications?
Any surgeries in the past?
Past h/o sexually transmitted infections?
When was your last PAP test & results?
Family and Social History
Do you smoke or consume alcohol?
Do you use recreational drugs?
Currently in a relationship? How long?
Sexual orientation?
Are you at risk of abuse?
Any family history of cancers?
Differential Diagnosis
Pelvic Inflammatory Disease caused due to sexually transmitted infections, IUDs.
Ovarian cyst.
Endometriosis.
Ovarian torsion.
Acute appendicitis.
Investigations
CBC
Vaginal & Cervical swabs, culture/sensitivity.
Urine culture/sensitivity.
Beta HCG
Pelvic ultrasound.
Management
Inj Ceftriaxone 250 mg IM stat dose with
Tab Doxycycline 100 mg PO bid x 14 days.
Reportable disease.
Treat partners.
Avoid intercourse till completion of treatment.
Practice safe sex.
Retest with cervical swabs after 4-6 weeks.
Julia Marshall, a 30 years old lady presented to the ER with bright red vaginal bleeding for the past 1 hour.
She is 36 weeks pregnant. Take a focused history and address her concerns.
Vitals: BP - 100/70 mm Hg. HR - 100/min. RK - 14/min.Temp - 37.5C
Clinical Info: Ms Julia Marshall is G2 Tl PO AO Ll at 36 weeks gestation. She has painless vaginal bleeding
for the past 1 hour. Has no contractions. Fetal heart rate is 130/minute. She has a previous history of
cesarean section.
Clinical Case : Placenta Previa
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Since how long have you noticed the bleeding?
Amount of bleeding?
Color of bleeding?
Number of pads changed?
Any passage of clots?
Any leaking noticed per vagina?
Any trauma recendy?
Are fetal movements felt?
Any abdominal pain?
Any fever/nausea/vomiting?
Any changes in bowel & urinary habits?
When was the last intercourse?
Date of last menstrual period?
Anv complications in the antenatal period?
When was the last antenatal visit?
Any bleeding episode during pregnancy?
Blood group?
Gynecological History
Regular/irregular menses?
Obstetrical History
Do you have children? If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple
births, complications in pregnancy.
H/o ectopic pregnancy?
H/o placenta previa/ abruptio placentae?
H/o of cesarean section and the reason?
Any surgeries on the uterus?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Are you allergic to any medications?
Family and Social History
Do you smoke or consume alcohol?
Do you use recreational drugs?
Elaine Abraham, a 32 years old lady primigravida, at 34 weeks gestation presented to the ER with
headache, abdominal pain and blurring of vision. Take a focused history and address her concerns.
Vitals: BP - 150/100 mm Hg. HR - 90/min. RR - 14/min.Temp - 37.0C. FHR - 148/min.
Clinical Info: Ms Elaine Abraham has a history of pregnancy induced hypertension since 28 weeks. Her BP
is controlled by dietary restrictions and low salt intake, ohe has epigastric pain, blurring and headache for
the
East 4-6 hours. She has facial and ankle edema ++. There are no contractions. Fetal movements are felt.
No leeding. Urine dipstick is positive for proteinuria.
Clinical Case : Pre Eclampsia
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Since how long have you noticed the pain?
Where is the pain located?
Sharp or dull pain?
Does the pain radiate or shoot anywhere?
Severity of pain on a scale of 1-10.
Onset of headache?
Location of headache?
Type of headache?
Onset of blurring of vision?
Do your symptoms change with time?
H/o fever/cough/rash/vomiting?
Any changes in bowel & urinary habits?
Any bleeding per vagina?
Any swelling of the body?
Fetal movements?
Any contractions/ leaking per vagina?
Total weight gain in the pregnancy?
Any antenatal complications like high blood pressure/diabetes/ seizures?
Gynecological History
Regular/irregular?
Obstetrical History
Do you have children?
If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple births, complications in
pregnancy.
H/o ectopic pregnancy?
Last antenatal visit?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Are you allergic to any medications?
Any surgeries in the past?
Family and Social History
Do you smoke or consume alcohol?
Do you use recreational drugs?
Are you at risk of abuse?
Any family history of hypertension/diabetes?
Diagnosis
Gestational hypertension with Preeclampsia.
Investigations
CBC, electrolytes, renal function tests.
Urinalysis, 24 hour urinary protein, liver function tests, uric acid, Ll)H, albumin.
INR, PTT, Fibrinogen.
Non stress test, Bio-physical profile.
Fetal ultrasound.
Management
Admit in the hospital.
Electronic Fetal monitoring.
Bed rest in left lateral decubitus position.
Hourly maternal vital signs with intake/output charting.
Inj Magnesium sulphate 4 mg IV bolus over 20 min,then 2-4g/h for maintenance.
Monitor signs for magnesium toxicity.
Inj Labetalol 20-50 mg IV qlOminutes till Br< 140/90 mmHg.
Deliver the baby.
RISK FACTORS FOR PIH:
Maternal: Primigravida or new paternity, Family hx of Preeclampsia, Diabetes Mellitus, Obesity, Maternal age >40 years,
Preexisting Hypertension, Anti-Phospholipid Antibody syndrome.
Fetal: IUGR, Oligohydraminos, Gtn. hydrops, Multiple pregnancy.
Michael Walter a 18 months old boy brought to your office by his mother regarding poor weight gain. Take
history from the mother & address nis concerns.
Clinical Info: Michael's mother is concerned regarding poor weight gain for his age & height. He has no
fever/nausea/vomiting/cough. No h/o recurrent infections. No urinary or bowel complaints. He's picky eater
who gets distracted while eating food. His diet consists of excessive juice & milk. No family stress present.
Clinical Case Diagnosis: Failure to thrive due to inadequate dietary intake.
HOPI
OCD PQRST UV + AAA
Duration of poor weight gain?
Sudden or gradual decline in weight?
Quality ana Quantity of food?
Who feeds the child?
Does the child feed self(e.g. spoon, cup)?
Psychosocial events around feeding time.
Is the child distracted or not supervised?
Are there food battles or food refusal?
Discuss food preparation (e.g. formula too dilute).
Beverages (e.g. Milk, juice, water, soda).
Stool habits (e.g. frequency and consistency).
Pica history.
Detailed nursing or breast feeding history.
Infrequent brief feedings.
Current weight & heignt?
Highest weight?
Any fever/nausea/vomiting/cough?
Any diarrhea/constipation?
Any urinary complaints?
H/o recurrent infections?
Maternal ingestion of alcohol/diuretics.
Inadequate milk supply.
Developmental history.
Child's medical history.
What body parts are affected and in what
order, premonitory signs?
Immunization history.
Post-ictal state (decrease in level of
Family history of seizure disorder.
consciousness, headache, weakness).
Screen for signs of child abuse.
Previous seizure?
Events during the seizure time?
How did the seizure stop?
Onset of fever? Sudden or gradual?
Duration of fever?
Type of fever-continuous, remittent,
intermittent.
Any nausea/vomiting?
Any ear/eye discharge/runny nose?
Any rash?
Any cough/sore throat/difficulty swallowing?
Any difficulty breathing?
Any bowel or urinary complaints?
Any sick contacts?
Ask about preceding trauma or illness or
medications taken?
Differential Diagnosis
Management
Febrile seizure.
Symptomatic treatment.
Meningitis.
Antipyretics for fever prn.
Encephalitis.
Maintain hydration.
Investigations
Counseling & reassurance for parents.
Recurrence - rectal or sublingual Lorazepam.
CBC, electrolytes, RFT.
Treat underlying cause of fever.
ABG, Blood glucose.
Urinalysis.
Blood culture &c sensitivity.
LP-gram stain, culture Sc sensitivity.
Nick Chang is a 15 years old boy brought by his mother with fever and rash for the past 2 days.
Take history & address her concerns.
Clinical Info: Nick has high fever for the past 2 days. He has developed a diffuse rash in the last 24 hours
which is spreading from head to trunk. He also has cough, sore throat and redness of eyes. He has no
altered level of consciousness/irritability. He is alert and feeding well. Has h/o sick contacts with similar
complaints in the day care. His immunization is up to date.
Diagnosis: Measles.
HOPI
OCD PQRST UV + AAA
Onset of fever- sudden or gradual?
Duration of fever?
Type of fevercontinuous,remittent,intermittent?
Highest recorded temperature?
Relieving factors for the fever?
Onset of rash?
Type of rash?
Location of rash?
Marie Jones delivered baby Anthony 36 hours old and now the newborn has jaundice, lethargy and crying.
The serum bilirubin is 220 mmol ( N < 200). Take history & address her concerns.
Clinical Info: Anthony was born to a primigravida by normal vaginal delivery. Mother noticed yellowish
discoloration of his eyes in the morning. She had no antenatal complications. She had premature rupture
of membranes prior to onset of labor at 38 weeks. She was put on antibiotics. Her labor was 18 hours long.
The labor was induced. Apgar was 9/10. Baby is a little lethargic and not feeding well. Has no fever/altered
consciousness. No seizures.
Clinical Case Diagnosis: Neonatal Jaundice due to Sepsis.
HOPI
Mother's obstetrical history:
GTPAL
H/o neonatal jaundice in past pregnancies.
Maternal medical history esp. liver disease.
Illness during pregnancy esp. diabetes, rubella, toxoplasmosis, hemes, CMV.
Teratogenic medications during pregnancy.
Radiation exposure in pregnancy?
Drug and alcohol use during pregnancy?
Any pets in the house?
Maternal & Paternal blood type.
Complications of present pregnancy.
- Gestational hypertension or diabetes, hyper/hypothyroid, hypercoagulation.
Any antenatal/post partum complications?
Newborn history:
Gestational age at birth,
Mode of delivery: cesarean, induction, forceps or vacuum delivery.
Duration of rupture of membranes (ROM)?
Was ROM artificial or prolonged?
Any fetal distress?Was meconium passed in utero?
APGAR score at birth, 1 minute & 5 minutes?
Was resuscitation required?
When was breast feeding started?
Is the baby feeding well?
Sean Radcliffe is a 8 years old boy whose parents have concern about bed wetting. Take history from the
father Sc address his concerns.
Clinical Info: Sean has been wetting his bed since the last 3 years. He never had bladder control. He has no
fever/vomiting. No h/o recurrent infections. He wets bed 2-3 times in the night. No day time wetting
present. No encoparesis. Parents have not taken any treatment so far and have tried toilet training in past
with no success. No stresses at home or school.
Clinical Case Diagnosis: Primary nocturnal enuresis.
HOPI
OCD PQJtST UV + AAA
Type of voiding - Involuntary or intentional.
Number of times wets bed in the night?
Has the child ever been dry?(primary or secondary)
Is there aaytime Enuresis?(complicated Enuresis)
Wetting pattern - daynight or night only.
Any dysuria/pyuria/foul smelling urine?
Involuntary passage of stool in the sleep?
Functional bladder disorder signs like
- Voids >7 times per day with urgency Sc in small volumes.
- Withholds urine until last minute, wets more than once nightly.
Has enuresis on only a few nights per week?
Voids large volumes when enuresis occurs?
Bowel or bladder habit changes recently.
Infrequent or difficult stool passage?
Any changes in appetite/weight?
Any fever/nausea/vomiting?
Any recurrent infections?
Amount of fluid intake prior to sleep?
Any neurological disorders?
Any genitourinary surgeries?
Enuresis in other siblings?
Derek Paul, a 65 years old man admitted in surgical floor presented with strange behavior for the past 4
hours. You are on call surgical resident for the shift. Take nistory & counsel.
Clinical Info: Mr Derek Paul had partial right hip replacement 3 days ago. His post op recovery till now has
been uneventful. Evening shift nurse noticed significant change in his behavior. He is agitated, resdess
with acute memory loss. He is disoriented to time, place 8c person. He is having delusional thoughts of
ants crawling. He is on oral antibiotics, antihypertensives, blood thinners. He is a chronic alcohol abuser.
Clinical Case : Delirium
HOPI
When did you notice the change in behavior?
Duration of symptoms?
Symptoms have worsened or improved?
Do you feel persistently cheerful/high?
Do you sense things that others around you don t?
Do you hear any voices?
Do you feel restless/agitated?
Any changes in memory?
Orientation to time/place/person?
Any fever/nausea/vomiting?
Claire Wiggins, a 72 years old lady brought to your office by her son with strange behavior. Take history
from the patient and address her concerns.
Clinical Info: Ms Claire Wiggins is forgetting things and daily tasks for the past 1 year. Her symptoms have
become worse for the last 6 months. Recently she forgot her way back home. She lives alone. Son has
noticed changes in her dressing and poor hygiene. She has no apparent psycho-motor or suicidal ideation.
She has hypertension. No past history of psychiatric illness. Currently on oral antihypertensives, statins,
zoloft, multivitamins.
Clinical Case : Dementia
HOPI
When did you notice the change in behavior?
Duration of symptoms?
Have you found yourself forgetting things? (establish onset, duration, degree)
Do you ever get confused or disorientated?
Do you have trouble understanding what people say to you?
Do you have trouble finding the right words to say?
Symptoms getting gradually worse over months?
Have you seen, heard or felt anything that other people told you didnt exist?
Have you noticed a change in your sense of smell?
Have you had any incontinence?
Any cnanges in gait?
Any mood changes?
Any fever/nausea/vomiting/abdominal pain?
Has there been a change in personality?
Do you have any medical/surgical illnesses? Ask details.
Do you take any medications? Ask details.
Do you consume alcohol? Amount/frequency?
Do you smoke? Duration/frequency?
Do you use recreational drugs? Ask TRAPPED.
Past Psychiatric History
Any similar symptoms in past?
Any h/o mania/ depression/ delusion/ delirium?
Any contacts with mental health professionals?
Any past problems with law?
Family History
Any family history of similar complaints?
Any family history of other psychiatric illnesses?
Any family history of suicide/alcohol/drug abuse?
Social History
Support system at home/work?
Current living situation?
Relationship nistory?
Education history?
Any risk of physical/sexual/mental abuse?
Activities of daily living & Instrumental Activities of daily living.
Differential Diagnosis
Alzheimer's disease.
MRI/CT Head.
MSE/MMSE.
Multi-Infarct dementia.
Dementia with Lewy bodies.
Management
Depression.
Educational brochures.
CBC, electrolytes, renal function tests.
Resources for the family.
Acetylcholinesterase inhibitors.
Julian Smith, a 56 years old lady brought to your office by her husband with strange behavior. Take history
& counsel.
Clinical Info: Ms Julian Smith has h/o of change in mood for the past 1 month after loosing her job. She has
changes in mood, sleep and appetite. She has lost 10 lbs in the last 1 month. She has lack ofinterest in
social activities. She has no apparent psycho-motor or suicidal ideation. She has no medical illnesses. No
past history ofpsychiatric illness. Currently not taking any medications.
Clinical Case : Depression
HOPI
When did you notice the change in behavior?
Duration of symptoms?
Symptoms have worsened or improved?
Any recent stressors at home or work?
Changes in sleep pattern?
H/o lack of interest recendy?
Feeling of guilt/hopelessness/ helpless/worthless?
Lack of energy?
Changes in mood?
Are you crying a lot?
Is your mood always low or it alternates?
Any changes in concentration?
Any changes in appetite?
Any changes in weight?
Any changes in memory?
Do you feel slowed down?
Do you feel resdess/agitated?
Any thoughts of harming self/suicide?
Any thoughts of harming someone else?
Any plans at the moment?
Do you feel persistendy cheerful/high?
Do you sense things that others around you dont?
Do you have any medical/surgical illnesses? Ask details.
Do you take any medications? Ask details.
Do you consume alcohol and smoke? Amount/frequency?
Do you use recreational drugs? Ask TRAPPED.
Past Psychiatric History
Any similar symptoms in past?
Any h/o mania/depression/delusion/ delirium?
Any contacts with mental health professionals?
Any past problems with law?
Family History
Any family history of similar complaints?
Any family history of other psychiatric illnesses?
Any family history of suicide/alcohol/ drug abuse?
Social History
Support system at home/work?
Current living situation?
Relationship history?
Education history?
Any risk of physical/sexual/mental abuse?
Differential Diagnosis
Major Depressive Episode.
Adjustment disorder with depressed mood.
Bipolar affective disorder.
Anxiety disorder.
Investigations
CBC, electrolytes, renal function tests.
TSH, blood glucose, urinalysis.
MSE/MMSE.
Management
Start SSRI.
Psychotherapy/CBT.
Educational brochures about depression.
Info about the side effects of medications.
Emphasis on long term management,follow up and compliance.
Referral to community resources.
Contract: Pt to contact you/family doctor/ nearest emergency/friend/family/crisis help line in case of
suicidal or homicidal ideation.
Brad Daniels, a 22 years old man came to your office with light headedness, trembling and chest pain for
the past 4 hours. Take nistory & counsel.
Clinical Info: Mr Brad Daniels is a university student who presented with sudden onset of light headedness,
trembling of body and chest pain prior to his presentation in class. He also complaints of palpitations and
shortness of breath. He had similar episodes in the past. No past history of psychiatric or medical illnesses.
Not taking any medications currently.
Clinical Case : Panic Attack
HOPI
When did you notice the symptoms?
Duration of symptoms?
Symptoms have worsened or improved?
Any recent stressors at home or work?
Do you have excessive sweating?
Do you experience tremors?
Do you have unsteadiness/dizziness?
Do you sense things that others around you don t? (Derealization)
Do you ever feel you are outside of yourself? (Depersonalization)
Do you have excessive heart rate?
Nausea/vomiting?
Any tingling/paresthesias?
Any shortness of breath?
Any fear of dying/loosing control/going crazy?
Do you have chest pain?
Do you have chills/choking sensation?
Changes in sleep pattern?
Feeling of guilt/ hopelessness/ helplessness/ worthless?
Any changes in mood?
Any changes in concentration?
Any changes in appetite/weight?
Any changes in bowel habits?
Any changes in memory?
Do you feel slowed down?
Do you feel restless/agitated?
Amount of caffeine intake?
Any anticipatory anxiety?
Worry about consequences of another attack?
Any thoughts of harming self/suicide?
Any thoughts of harming someone else?
Do you have any medical/ surgical illnesses?
Do you take any medications? Ask details.
Start SSRI.
Panic disorder.
Anxiety disorder.
Psychotherapy/CBT.
Educational brochures about anxiety attacks.
Mood disorder.
Contract: Pt. to contact you/family doctor/ nearest emergency/friend/family/crisis help line in case of
suicidal or homicidal ideation.
Liam Pinkerton, a 24 years old male was brought to the ER with complaints of alien attacks . Take history &
counsel.
Clinical Info: Mr Liam Pinkerton is brought by police with complaints of being attacked by aliens in the last
48 hours. He is talking to himself and avoiding direct eye contact. He is restless and agitated and feels
threatened. He is hearing strange voices for the past 1 month along with disorganized speech and
behavior. He is a chronic cocaine user for the past 3 years and increased consumption in last 48 hours.
Clinical Case : Schizophrenia
HOPI
Thought phenomena:
Think your thoughts are interfered with in any way?
Think others can read your thoughts?
Think an outside entity is affecting your thoughts?
Hear echo's of your thoughts like a voice?
Delusions:
Anything bothering you at the moment?
Ever felt that someone is out to get you?
Earents car in a tree. She attempted to commit suicide to prevent embarrassment. She went to her
friend's ouse after the accident. Her grandma brought her to the ER. Has h/o previous attempt 1 year ago.
Is currendv consulting a psychiatrist on a regular basis. Presendy on antidepressants. Show EMPATHY!
Clinical Case : Suicide
HOPI
Analyze the attemptVv hen / What method / Source of method / Circumstances which lead to the attempt
What were your thoughts while hurting yourself?
What did you think would be the outcome?
Changes in mood?
H/o lack of interest recently?
Feeling of guilt/hopelessness/helplessness/ worthlessness?
Lack of energy/concentration?
Is your mooa always low or it alternates?
Any changes in appetite/weight?
Do you feel restless/agitated?
Any thoughts of harming someone else?
Any plans at the moment?
Do you sense things that others around you dont?
Do you have any medical/surgical illnesses? Ask details.
Do you take any medications? Ask details.
Do you consume alcohol? Amount/frequency?
Do you smoke? Frequency/duration?
Suicidal Attempt.
Investigations
CBC, electrolytes, renal function tests.
Liver function tests, Blood gases.
Se. salicylate levels q2h till levels fall.
Blood glucose, urinalysis.
Management
Admit under FORM 1.
Gastric Lavage.
Urine alkalinization.
Urgent psychiatric evaluation.
Arrange family meeting and involve social worker.
Start Lithium or Clozapine.
Do you use recreational drugs? Ask TRAPPED.
Past Psychiatric History
Any similar attempts in the past? Outcome/admission, if any?
Treatment given for such attempts?
Any h/o mania/ depression/ delusion/ delirium?
Any contacts with mental health professionals?
Any past problems with law?
Family Histoiy
Any family history of suicidal attempts?
Any family history of other psychiatric illnesses?
Any family history of suicide/alcohol/drug abuse?
Social History
Support system at home/work?
Current living situation?
Relationship nistory?
Education history?
Any risk of physical/sexual/mental abuse?
Assess Suicidal risk: SAD PERSONS Sex - Male> female
Age - Bimodal: 15-25 years and > 65 years.
Depression
Previous attempts
Ethanol use
Rational thinking
Suicide in family
Organized plan
No support
Sickness
Based on the score from the scale:
0-2 - Send home with family.
3-4 - Close follow up, consider admission. 5-6 - Strongly consider admission.
7-10 - Admit.
Complete physical examination.
Squamous Cell Carcinoma.
Cryotherapy.
Investigations
Jacob Simpson, 62 year old man presents to the Emergency Department with 12 hours suprapubic
discomfort and inability to urinate. Take a focused history & perform a focused examination.
Clinical Info: Mr Jacob Simpson presented with acute urinaiy retention for the past 12 hours. He is having
difficulty passing urine for the past 4 months, which has gradually increased. He has hesitancy, urgency,
increased frequency and weak stream. No hematuria or UTI. O/E there is a palpable supra-pubic mass.
Catheterization[yields 1200cc urine.
Clinical Case : Benign Prostatic Hyperplasia
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of inability to pass urine?
Any pain associated?
Location of pain?
Type of pain - sharp or dull?
Severity of pain on a scale of 1-10.
Do your symptoms change with time?
Difficulty initiating or maintaining urinary stream?
H/O weak/interrupted urinary stream.
Feeling of incomplete bladder emptying?
Any nocturia/ urgency/ increased frequency?
Color of urine? Any blood in urine?
H/O recurrent urinary infections?
H/O renal pain or groin pain?
H/O fever, night sweats, weight loss, fatigue?
Any bowel complaints?
Any perineal numbness / leg weakness?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Are you allergic to any medications?
Previous renal colic / diagnosed prostate hypertrophy?
H/O prostate cancer, prostatism, nephrolithiasis, UTIs? H/O pelvic radiation?
Any h/o past surgeries? TURP?
Family and Social History
Any family history of cancer / similar complaints?
Currendy in a relationship?
Practicing safe sex?
Do you think you are at risk of getting STIs?
Do you smoke? Duration & frequency.
Lydia Jones, a 30 years old office lady presented to your office with right hand numbness and weakness for
2 months. Take a focused history and address her concerns.
Clinical info: Ms Lydia Jones presented with gradual onset of right hand numbness and weakness for the
past 2 months. Her symptoms have worsened. Associated with paresthesias and pain in fingers at the end
of the day. She has difficulty opening jars, turning keys and night pains. She has no medical illness. Not on
any medications. She is an office administrator.
Clinical Case : Carpal Tunnel Syndrome
HOPI
OCD PQRST UV + AAA
Handedness - left or right?
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of numbness?
Location of numbness?
Any paresthesias/tingling/swelling?
Any weakness or muscle pain?
Is mere any associated pain?
Any difficulty opening jars/turning keys?
Any symptoms in night time?
Any abnormal position of the hand?
Any neck pain/upper arm weakness?
Similar symptoms in other parts of the body?
Do your symptoms change with time?
Any changes in vision/speech/headache?
Any changes in gait?
Occupation?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Are you allergic to any medications?
Any surgeries in the past?
Family and Social Histoiy
Do you smoke? Duration & frequency.
Do you consume alcohol? Duration & frequency.
Any family history of thyroid disease?
Any family history of cancers/ medical illnesses?
Differential Diagnosis
Carpal Tunnel Syndrome.
Cervical radiculopathy.
TIA.
Investigations
CBC, blood glucose, electrolytes.
C-spine X ray.
Nerve conduction studies.
Management
Modify manual work.
Wrist splint (often worn at night).
NSAIDs, local corticosteroid injections.
Control underlying systemic contributors (e.g. diabetes, hypothyroidism, arthritis).
Surgical decompression via flexor retinaculum release.
Orthopedic or Plastic surgery consult.
Lupus anticoagulant.
Doppler of lower limbs.
Impedance plethysmography.
Management
Urgent medicine consult.
Low molecular weight heparin x 3 days.
Then switch to Warfarin.
IVC filters (only if anticoagulation is contradicted).
Mathew Hobbs, a 55 years old man presented with numbness in his both feet. He is a known diabetic. Take
a focused history and perform focused physical examination.
Vitals: BP - 130/90 mm Hg, HR - 86/min, RR - 14/min,Temp - 38.5C.
Clinical Info: Mr Mathew Hobbs is a known diabetic for the past 15 years. He is on oral hypoglycemics. His
last fasting glucose was 7.6 mmol/L. On examination, both feet were normal.
Clinical Case : Diabetic Foot
HOPI
OCD PQRST UV + AAA
How did numbness start? Sudden or
gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of numbness?
Location of numbness?
Is there any pain associated with numbness? Type of pain - sharp or dull pain?
Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10.
Do your symptoms change with time?
H/o tingling?
Any recent injury to feet?
Any blisters/calluses on the feet?
Any swelling of feet?
Any changes in vision?
H/o dizziness / LOC?
H/o chest pain/orthopnea?
H/o excessive sweating?
Any changes in appetite?
Any changes in weight?
Any changes in bowel Sc urinary habits? Last fasting blood sugar, eye ana foot exam?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Are you allergic to any medications?
Any surgeries in the past?
Past h/o recurrent infections?
Family and Social History
Do you smoke? Duration and frequency.
Do you consume alcohol? If yes, duration, amount and frequency.
Do you use recreational drugs? TRAPPED
Any family history of cancers/medical illnesses?
Exercise schedule.
Dietary restrictions for diabetes.
Compliance with medications?
Diagnosis
Diabetic foot
Investigations
Fasting blood glucose.
HbAlC.
Fasting lipids, Renal function tests.
ECG.
Fundoscopy.
Urinalysis with urine dip.
Management
Self foot exam daily.
Wayne Singer, 68 year old man presented with difficulty swallowing for the past 4 months. Take a focused
history and perform a focused examination.
Clinical Info: Mr Wayne Singer has difficulty swallowing for the past 4 months. It has gradually increased
from solids to liquids. He feels a lump in the throat. He has chest pain when he eats food. He has noticed
weight loss, night sweats and decreased appetite in the last 3 months. He is a chronic smoker for the past
30 years.
Clinical Case : Difficulty Swallowing ( Ca Oesophagus)
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of difficulty swallowing?
Is there difficulty transferring food from mouth to esophagus (suggestive of oropharyngeal dysphagia) or
further down (suggestive of esophageal dysphagia)?
Is me problem worse with solids (suggests mechanical obstruction) or liquids (suggests neuromuscular
dysfunction, often can't swallow both solids and liquids)?
Is there a sensation of lump in the throat (globus hystericus)?
Progression of difficulty swallowing solids to difficulty in swallowing liquid? (Suggests a worsening
stricture of growing tumor)
Any swelling the neck?
Aggravating, relieving factors? The association of intermittent obstruction and chest pain suggests
esophageal spasm.
H/O peptic ulcer, reflux, hiatus hernia?
H/O fever, night sweats, weight loss, fatigue, hematemesis, black stools?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Are you allergic to any medications?
Any surgeries in the past?
Any history of goitre or thyroid problems?
Any radiation exposure?
Family and Social History
Do you smoke? Duration &, frequency.
Do you consume alcohol? Duration & frequency.
Any family history of thyroid disease?
Any family history of cancers/ medical illnesses?
Differential Diagnosis
Esophageal Cancer.
Stricture due to GERD/Trauma.
Neuromuscular obstruction - achalasia, cranial nerve palsy, MS, supranuclear palsy, stroke, motor neuron
disease, myasthenia gravis, muscular dystrophy.
Investigations
Endoscopy with biopsy.
Upper Gl series.
CT chest (for mediastinal and lymph node involvement).
Chest X-ray.
LFTs, RFT.
Abdominal ultrasound.
CBC.
Management
Urgent surgical consult.
Brad Chisolm, a 35 years old man presented with bloody vomiting to the ER for the past 2 hours. Take a
focused history and perform focused physical examination.
Vitals: BP - 90/60 mm Hg, HR - 116/min, RR - 12/min,Temp - 37.0C
Clinical Info: Mr Brad Chisolm presented with acute onset of blood in vomitus, 2 episodes in 2 hours ago.
He has no history of trauma. Non alcoholic, non smoker. He has been having chronic knee pain after a
skateboarding accident 2 weeks ago. He is taking Ibuprofen for the past 2 weeks 4-5 times a day. Has
moderate epigastric pain. No hemoptysis, hematuria or hematochezia. No surgeries/ medical illnesses.
Clinical Case : Hematemesis
HOPI
OCD PQRST UV + AAA How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of blood in vomitus?
Amount of blood?
Color of blood?
Number of episodes?
Is there any abdominal pain?
Type of pain - sharp or dull pain?
Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10.
Do your symptoms change with time? Any blood wnile coughing?
Any blood in stools/last bowel movement? Any blood in urine?
Any trauma to abdomen?
Any fever recently?
Any dizziness/fainting?
Currently on any mdications?
Last meal?
Any allergic reactions?
Past History
Do you have medical illnesses?
Any surgeries in the past?
Family and Social History
Do you smoke? Duration & frequency.
Do you consume alcohol? Duration & frequency.
Any family history of cancers/ medical
Do you take any recreational drugs?
Any family history of cancers/ medical illnesses?
Differential Diagnosis
Management
Gastric ulcer.
ABC.
Acute Esophagitis.
Admit.
Acute gastritis.
NPO.
Drug induced coagulopathy.
NG tube.
IVF via large bore cannulas.
Investigations
CBC, electrolytes, glucose.
Inj Ranitidine 50 me IV bolus and q8h.
In case of perforated ulcer - surgery consult.
LFT, RFT.
PT, PTT, INR.
Blood group & cross match.
Urgent endoscopy.
Upright abdominal X Ray.
Clinical info: Ms Mary Laplante noticed this swelling in the anterior neck with no other prominent
symptoms. On examination, there is 2cm x 2cm mobile, non tender thyroid enlargement in the left lobe.
Clinical Case : Neck Swelling
HOPI
OCD PQRST UV + AAA
How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Since how long have you noticed the lump?
Where is the lump located?
How does the lump feel like?
Is there any pain associated with the lump?
Type of pain - sharp or dull pain?
Does the pain radiate or shoot anywhere?
Severity of pain on a scale of 1-10.
Do your symptoms change with time?
H/o fever/cough/sore throat?
Any weakness or myalgia?
Any change in voice?
Any change in vision?
Any change in appetite?
Any change in weight?
Any changes in bowel & urinary habits?
Any temperature intolerance?
Any palpitations or tremors?
Any swelling of face or feet?
Last menstrual period?
Any changes in menstrual cycles?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Are you allergic to any medications?
Any surgeries in the past?
Any history of goitre or thyroid problems?
Any radiation exposure?
Family and Social History
Do you smoke? Duration and frequency.
Do you consume alcohol? If yes, duration, amount and frequency.
Any family history oi thyroid disease?
Any family history of cancers/medical illnesses?
Differential Diagnosis
Toxic nodular goitre.
Hashimotos thyroiditis.
Thyroid cyst.
Thyroid adenoma.
Thyroid lymphoma.
Investigations
TSH.
Free T3 and T4.
Thyroid ultrasound.
Thyroid biopsy.
Antimicrosomal & anti-thyroglobulin abs.
Management
Refer to an endocrinologist.
HOPI
OCD PQRST UV + AAA How did it start? Sudden or gradual.
Is it getting worse/better or no changes in the symptoms?
Duration of abdominal pain?
Where is the pain located?
Type of pain - sharp or dull?
Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10.
Do your symptoms change with time?
Any aggravating or relieving factors (change in position/food intake)?
Effect on activities of daily living, functional limitation?
H/o fever, nausea/vomiting, dizziness / fainting?
Any urinary complaints?
Loose stools /black stools or blood in stools? Change in stool caliber?
Females :
LMP?
Pain associated with periods?
Vaginal discharge?
Past History
Do you have diabetes or hypertension?
Are you on any medications?
Are you allergic to any medications?
Any surgeries in the past?
Family and Social Histoiy
Do you smoke? Duration & frequency.
Do you consume alcohol? Duration & frequency.
Do you use recreational drugs? TRAPPED.
Any family history of cancers/ medical illnesses?
Differential Diagnosis
Management
Appendicitis.
Admit.
surg*cal consultation.
Renal colic due to nephrolithiasis.
PID.
IV Antibiotics.
Ectopic pregnancy.
Ruptured Ovarian cyst or ovarian torsion.
Mittelschmerz syndrome.
Investigations
Abdominal X-ray 3 views
Abdominal 8c pelvic ultrasound
CBC, Electrolytes, Urea, Creatinine
INR/PTT, Glucose, beta HCG
Urinalysis
Stool for occult blood
Cervical swabs for culture/ PAP smear
NPO, NG tube.
Elaine Jones, a 60 years old lady presented with swelling in the neck for the past 4 months. Take a focused
history and perform focused physical examination.
Vitals: BP - 120/80 mm Hg, HR - 88/min, RR - 12/min,Temp - 37.5C.
Clinical info: Ms Elaine Jones presented with a solitary swelling in the right lobe of the thyroid for the past 4
months. The swelling has increased in size. She has no fever, cough or sore throat. She has decreased
appetite and 5 kg weight loss in the past 3 months. She has hoarseness of voice.
Clinical Case : Thyroid mass
HOPI
Past History
OCD PQRST UV + AAA
Do you have diabetes or hypertension?
How did it start? Sudden or gradual.
Are you on any medications?
Is it getting worse/better or no changes in
Are you allergic to any medications?
the symptoms?
Any surgeries in the past?
Since how long have you noticed the
Any history of goitre or thyroid problems?
swelling?
Any radiation exposure?
Where is the swelling located?
Joseph Quinton, a 25 years old male was brought to the ER after a motor vehicle accident with the
following vitals: BP - 80/50 mm Hg, HR - 116/min, RK - 10/min,Temp - 37.0C, 02 sat - 80%.
Manage the patient with a nurse.
Clinical Info : Mr Joseph Quinton had a MVA 1 hour ago. He is conscious, alert and responding to verbal
commands. He is in excruciating pain & complains of difficulty breathing. He can move all limbs. On
auscultation, there are decreased breath sounds on right side oi chest with dullness on percussion.
Diagnosis: Trauma - Right sided hemothorax.
Introduce yourself.
Call out the patient's name and assess verbal response.
Follow universal precautions - mask,wash hands,wear gloves.
Ask for patient's vitals.
Ask the patient to be connected to monitors: cardiac monitor, BP cuff, pulse oximeter, temperature probe.
rlace cervical collar with in-line traction.
AIRWAY - Open mouth & check airway for any loose body/dentures/bleeding. Mention any specific smell.
BREATHING - LOOK - cyanosis/pallor/icterus/nasal flaring/chest movements/respiratory rate/neck venous engorgement.
- FEEL - flow of air/tracheal shift/chest wall for crepitus/flail segments/sucking chest wounds/subcutaneous
emphysema.
- LISTEN - sounds of obstruction/breath sounds/symmetry of air entry/air escaping/noisy breathing.
CIRCULATION - feel for peripheral pulses/ assess for shock-capillary refill,cool extremeities. DISABILITY GCS/pupillary reaction.
Order primary INVESTIGATIONS - CBC, differentials, electrolytes, RFTs, LFTs, ABG, INR, PTT, 12 lead ECG,
urinalysis, urine toxicology screen, portable chest X ray, C-spine X ray, Blood group, type & cross match,
blood glucose.
Place large bore IV cannulas both arms & IVF 11 normal saline bolus stat.
Attach to 100 % oxygen through mask/nasal cannulas.
Ask for vitals again.
Ask for orientation to time/place/person, mechanism of injury/ any eye witnesses/ any loss of
consciousness/ vomiting/ pain anywhere in the body/ last meal/ any arug allergies/ TAMPLE or SAMPLE.
EXPOSURE/ SECONDARY SURVEY - Assess for:
- Skull/cranium fractures.
- Injuries to the face.
- Hemotympanum/ otorrhea/ rhinorrhea/ epistaxis/ batde's sign/ racoon eyes.
- Check upper extremities for fractures/ bruises/ lacerations/ tattoos/ needle track marks/ medic alert
bracelet/ scars/ wounds.
- Check abdomen for movements/ scars/ wounds/ bruises/ rigidity/ masses, bowel sounds.
- Check lower extremities for fractures/ bruises/ wounds/ tattoos/needle track marks.
- Pelvic compression to rule out pelvic fracture.
- Deep tendon reflexes of upper & lower extremities.
- Sensory examination of upper & lower extremities.
- Motor examination of upper & lower extremities.
- Genital examination.
- Spinal examination - log roll with help to look for fracture/ step deformity.
- Digital rectal examination.
- Change rigid board to semi rigid board.
Verbal
Makes no sounds
Incomprehensible
sounds
Utters
inappropriate
words
Confused,
disoriented
Oriented,
converses
normally
N/A
Motor
Makes no movements
Extension to painful stimuli (decerebrate response)
Abnormal flexion to painful stimuli (decorticate response)
Flexion / Withdrawal to painful stimuli
Localizes painful stimuli
Obeys
commands
Generally, brain Injury is classified as Severe : GCS < 8, Moderate : GCS 9-12 and Minor : GCS > 13.
Allison George, a 28 years old primigravida came to your clinic for her antenatal visit. She wants info for
breast feeding.
Take a focused history and address her concerns.
Counseling Case : Breast Feeding
HOPI
Current gestational age?
Any complications in the current pregnancy? GTPAL : Gravidity, Term pregnancies, Prematurity, Abortion,
Living children.
Last fetal ultrasound.
Any maternal screening till date for genetic disease?
Any genetic disorder in family ?
Any Breast feeding issues in previous pregnancies?
Any recurrent infections of the breast?
Any h/o HIV/HCV/HBsAg/active HSV?
Past History
Do you have any medical illnesses?
Are you on any medications?
Are you allergic to any medications?
Any surgeries in the past?
Any h/o cancer in the past?
Family and Social History
Do you smoke? Amount/frequency.
Do you consume alcohol?
Amount/frequency.
Do you use recreational drugs? TRAPPED.
Any family history of cancers (esp breast cancer)?
Counseling for Breast Feeding
Breast feeding has to be initiated immediately after birth.
Initial clear breast milk called COLOSTRUM is full of nutrients and immunoglobulins.
It is beneficial for developing immunity in the newborn.
Full milk production starts by 3-7 days.
Exclusive breast feeding is recommended during the first 4 months.
Breast milk is easily digested with minimal renal load.
Breast milk has low allergic potential than cow's milk protein.
Lower pH promotes growth of lactobacillus in the Gl tract.
Creates parent - child bonding.
Breast fed babies require following supplements: Vitamin K, Vitamin D, Iron (from 4months to 12
months), Fluoride(after 6 months).
Contraindications to breast feeding- Mother receiving chemotherapy.
- Mother with HlV/AIDS, active TB, herpes in the breast region.
- Mother consuming alcohol/illicit drugs.
- Mother on drugs contraindicated for breast feeding like antimetabolites, bromocriptine, chloramphenicol,
metronidazole, tetracycline, lithium, cyclophosphamide.
Complications of breast feeding - sore/cracked nipples, breast engorgement, mastitis, breast feeding
jaundice, breast milk jaundice, oral thrush in baby.
Breast feeding helps in losing pregnancy weight.
Lactational amenorrhea protects against future pregnancy.
Give educational info for breast feeding.
Rachel Marshall is a 20 months old girl brought to the ER with excessive crying. She has signs of fracture of
right humerus. You also observe some old healed bruises elsewhere on her body. She is now stable. Take
history from the mother and address her concerns.
Counseling Case : Child abuse
HOPI
How did the injury occur?
When did the injury occur?
Location of injury?
What was the child doing at the moment of injury?
Any loss of consciousness?
Any abnormal position or posture of the body?
Any seizures after the trauma?
Any vomiting?
Any excessive crying?
Any bleeding or discharge from nose/ears/ mouth?
Who are the child's care givers?
Who lives in the house or comes in contact with the child?
How did the child get the bruises?
What happened with the other fractures?
Any other injuries in the past?
Is the child accident prone or difficult to handle?
What is the child's personality: open vs. withdrawn?
Are there other children in the house?
Have they had broken bones or other injuries?
Was this child a planned pregnancy?
Problems with pregnancy, birth history? detailed history.
Developmental milestones. Detailed history.
What is the typical response of caregivers when the child cries or misbehaves?
Family and Social History
Do you smoke? Amount/frequency.
Do you consume alcohol? Amount/frequency.
Do you use recreational drues? TRAPPED.
Alcoholism/smoking/drug abuse by other caregivers?
Economic condition of the family?
Any problems with the law?
Were the caregivers abused as children?
Is there spousal abuse, sexual abuse or incest?
Has the Children's Aid Society been involved with this child or other children?
Counseling for child abuse
Do a complete physical examination of the baby.
Document and/or photograph all injuries: type, location, size, shape, color, pattern. Inform parents or care
takers about the suspicion of child abuse.
Order blood tests to rule out medical causes of presenting symptoms.
Sexually transmitted infection work up.
Skeletal survey/bone scan.
CT/MRI.
Fundoscopy.
Report all suspicious cases to the CHILDREN'S AID SOCIETY.
Admit for serious injuries.
Involve social worker and other community resources.
Inform that you are legally obliged to inform the Children's Aid Society.
Your duty to report overrides patient's confidentiality. Evaluate the risk factors for chi *
ild abuse:
- Environmental factors- Social isolation, poverty, domestic violence.
- Caregiver factors- Parents were abused as children, psychiatric illnesses, substance abuse, single parent
family, poor social & vocational skills, below average intelligence.
- Child factors- difficult temperament, disability, special needs(eg developmental delay), premature.
Sara Chang, a 55 years old lady came to your clinic to get info about Hormone Replacement Therapy. She
is menopausal for the past 2 years. She is having significant hot flushes, mood fluctuations and vaginal
dryness. It is significantly affecting her quality of life.
Take a focused nistory and address her concerns.
Counseling Case : Hormone replacement therapy
HOPI
Menopausal since when?
Any post menopausal bleeding/spotting?
HOPI
Any h/o breast lump/mass?
Any breast discharge?
Any nipple discharge?
Motivation: how would being at ideal body weight improve the patient's life?
Emphasize health, lifestyle, self esteem, relationship benefits.
Discuss nutrition-related problems: heart disease, obesity, hypertension, osteoporosis, anemia, dental
decay, cancer, gastrointestinal disorders, respiratory compromise, high lipids, diabetes, sleep apnea,
osteoarthritis.
Discuss diets tried and why these failed.
Fad diets involve unusual or extreme eating patterns and are not designed to be maintained for a lifetime
therefore these should be discouraged.
Weight loss agent Pondral no longer available.
SSRIs such as Paxil may assist with weight loss, unfortunately, when the drug is discontinued, most
people regain weight.
Explain mat the brain has a satiety set point which can be reset over time with reduction in caloric
intake.
Warn that the body's ability to determine caloric content is very good, and will not be fooled by so- called
diet products.
Recommend a balanced diet consisting of ordinary foods, with three distinct meals per day of small size.
No eating at night and be careful of snacks.
Inform patient that he will be hungry for at least the first two weeks of reduced intake.
Suggest visualization techniques, redirection of interests, and to think of hunger as a sign of positive
progress on weight loss.
Group support can be beneficial too: Weight watchers, overeaters anonymous etc.
HOPI
Duration of smoking?
Frequency of smoking in a day?
At what age did you start smoking?
What type of tobacco do you smoke- cigarette/ cigars/ pipe/filter/non filter?
When do you have your first cigarette of the day?
If you do not smoke for a while, do you experience cravings or withdrawal symptoms?
Which symptoms do you experience
- weak & tired?
- sad or blue?
- irritable or cranky?
- difficulty concentrating?
- restlessness?
- anxious or jittery?
What people,places or events make you crave a cigarette?
How does smoking help you?
Does smoking help or harm your relationships?
Counseling for smoking cessation
Do not judge the patient.
Recognize the readiness of the patient to quit smoking.
Be sympathetic to the patient.
Respect the patients decision.
Be familiar with the relevant information and resources for smoking cessation.
Encourage all efforts taken.
NOTES
mms
Alphabetical Index
Crohns Disease..............................................
.........17
Acute Gastroenteritis......................................
........16
48
Acute Myocardial Infarction..........................
7
Deep Vein Thrombosis - clinical case...........
,,146
Acute Otitis Media........................................
45
52
Acute Pancreatitis............................................
17
Delirium - clinical case..................................
,135
Acute Pharyngitis............................................
23
Delirium Tremens..........................................
36
Acute Pyelonephritis.......................................
, . .30
Dementia........................................................
, 55
Acute Sinusitis................................................
23
Dementia - clinical case.................................
.,136
Alcohol............................................................
,, .35
Depression......................................................
..........56
Alcohol withdrawal.........................................
30,59
Depression - clinical case...............................
137
Allen Test........................................................
,68
Diabetes Mellitus...........................................
.........14
Allergic reaction..............................................
Allergic Reaction.............................................
50
Diabetic Foot - clinical case...........................
,147
,30
Diabetic ketoacidosis.....................................
, 31
Anaphylaxis.....................................................
........30
Diabetic Ketoacidosis.....................................
14
Anemia............................................................
19,50
32
Ankle Anterior Drawer Test.........................
........84
Digoxin Toxicity - clinical case......................
,106
Anorexia - clinical case...................................
133
Diverticulitis...................................................
17
Antenatal Visit - clinical case.........................
119
Domestic violence - counseling.....................
......161
Anterior Drawer Test......................................
........82
Dysfunctional Uterine Bleeding....................
.........40
anti-hypertensive drugs...................................
Apley s Scratch Test........................................
........10
Dyslipidemia..................................................
...........9
........86
Dysmenorrhea................................................
40
Appendicitis....................................................
16
Ectopic Pregnancy.........................................
42
Apprehension Sign.........................................
,86
Ectopic Pregnancy - clinical case..................
.......120
Arrhythmias....................................................
........31
Emergency contraception..............................
.........41
ASA...............................................................
, ,31
Empty Can Test............................................
Endometriosis................................................
,, 86
Asthma............................................................
24,45
...... 40
Asthma - clinical case.....................................
103
Epiglottitis.....................................................
48
Athletes foot...................................................
13
Ethylene glycol..............................................
, 32
Atrial Fibrillation............................................
...8,102
Examination - Abdominal.............................
63
Atrial Fibrillation - clinical case.....................
102
Examination - Back/Spine............................
77
Atrophic vaginitis............................................
, .39
Examination - Breast.....................................
.........90
Back Pain - clinical case..................................
......142
Examination - Cardiovascular.......................
65
Bacterial Meningitis........................................
49
Examination - Central Nervous System......
.......71
Bacterial Pneumonia......................................
46
Examination - Elbow....................................
, 87
Bacterial Tracheitis..........................................
45
Examination - Foot and Ankle....................
..........83
Bacterial vaginosis...........................................
Basal Cell Carcinoma - clinical case..............
39
Examination - Hand and Wrist...................
.........88
......143
Examination - Hip........................................
79
Benien Prostatic Hyperplasia - clinical case... Bipolar disorder...............................................
144
Examination - Knee......................................
, 81
57
Examination - Lower Limb Neurological....
75
Bowstring test.................................................
78
Examination - Mini Mental State...............
93
Breast Feeding - counseling............................
, , 159
Examination - Peripheral Vascular..............
,67
Buergers Test..................................................
........68
Examination - Respiratory...........................
..........69
Bulimia - clinical case.....................................
134
Examination - Shoulder................................
85
Burns...............................................................
11
Examination - Thyroid.................................
.........91
Ca Oesophagus - clinical case........................
148
Examination - Upper Limb Neurological.... External Rotation Lag Sien..........................
..........73
Candidiasis......................................................
39
.........86
Carpal Tunnel Syndrome - clinical case.........
Cellulitis..........................................................
.......145
FABER..........................................................
78,80
, , 13
Laryngotracheobronchitis........................................48
Lasegues sign..........................................................78
Malaria.....................................................................20
Mammogram - counseling....................................163
Mania.......................................................................53
Mania - clinical case..............................................138
McMurray's Test......................................................82
Measles - clinical case............................................128
Meningitis................................................................21
Meningitis - clinical case.......................................109
Migraine..................................................................22
Mood stabilizers......................................................57
Myasthenia Gravis...................................................23
Neck Swelling - clinical case.................................150
Neer Impingement Sign..........................................86
Neonatal Jaundice - clinical case...........................129
Obesity - counseling..............................................165
Obsessive-compulsive disorder...............................55
OCP Counseling - clinical case.............................122
Opioid......................................................................33
Opioid Intoxication.................................................59
Osteoarthritis...........................................................26
Osteoporosis............................................................26
Ottawa Ankle rules..................................................84
Alphabetical Index
Rheumatoid Arthritis...............................................26
Romberg's test..........................................................72
Scabies......................................................................13
Schizophrenia - clinical case..................................140
Schober'sTest...........................................................78
Seizure disorder - clinical case...............................115
Seizures....................................................................21
Septic Arthritis.........................................................29
sexual dysfunction....................................................58
Sexually Transmitted Infection................................38
Shock........................................................................33
Smoking...................................................................35
Smoking - counseling............................................167
Social Phobia............................................................54
Solitary lung nodule - clinical case........................154
Speech delay - clinical case....................................132
Speed's Maneuver....................................................86
Sprain.......................................................................33
Straight leg raising test............................................78
Streptococcal Pharyngitis........................................48
Stroke.......................................................................33
Substance abuse........................................................59
Suicide - clinical case.............................................141
Alphabetical Index
Syphilis.....................................................................38
Talar Tilt Test...........................................................84
TCA.........................................................................34
Temporal arteritis.....................................................28
Temporal Arteritis - clinical case...........................116
Tennis Elbow..........................................................87
Tension headache.....................................................22
Tetanus.....................................................................21
Thomas test..............................................................80
Thompson's Test......................................................84
Thyroid mass - clinical case...................................155
Tinea Cruris.............................................................13
Tinel's sign...............................................................89
Trendelenberg test....................................................79
Trendelenburg Maneuver.........................................68
Trichomonas vaginalis..............................................39
Troisier's Sign...........................................................69
Tylenol......................................................................50
Ulcerative Colitis......................................................19
Urinary tract infection..............................................29
Urinary Tract Infection.......................................39,49
Viral Hepatitis - clinical case.................................117
Virchow s Node........................................................69
Vocal fremitus...........................................................70
Vulvovaginitis...........................................................39
Warfarin...................................................................34
Whooping Cough...................................................48
Yergason test.............................................................86