Bhatti Notes

Written by: SUB-34
For all my sweet friends…..
CASE PRESENTAION
INTRODUCTION
Hello Mr. Jones, (shake hand) Good morning. I am Dr. David, attending
physician in this hospital/medical center. Nice to meet u. I’ll be taking care of your health
today.
Are you feeling comfortable in this room?
If the patient is draped then,
Is there anything else I can do to make you more comfortable?
If the patient is not draped then,
Let me make you more comfortable by putting this drape over u. Is that ok?
So Mr. Jones, How can I help you today? Or
What brought u to the hospital today? Or
What made you come here today?
CHIEF COMPLAIN
Oh, I am sorry to hear about your problem, I’ll try my level best to help you out of this problem.
For that, I’ll ask you few questions and do a brief physical examination. Is that OK? Meanwhile
I’ll write few notes while we discuss if you don’t mind.
You will not shake hand with pt. if he is having right sided weakness (stroke) or he is presented
with pain in right arm and u suspect some kind of fracture.
Questionnaire:
DOPEFAAA
D: When did it start? Duration
O: How did it start? Onset
P: How is it progressing? Progression
E: What do you think that might be causing your problem?
F: Is it continuous/on and off? If on and off, how often does it come? How long does it last?
(Frequency)
A: What makes it better? Alleviate
A: What makes it worse? Aggravate
A: Associated symptoms
FOR PAIN
LIQR
L: Can you locate your pain? Location
I: On a scale of 1-10, 10 being worst pain of your life, how do you rate your pain? Intensity
Q: Can you describe your pain for me? Quality
R: Does your pain move anywhere else? Radiation

Now I would like to ask you few questions regarding your general health. Is that OK?
FNVTTTTT
F: Do you have fever? If yes then how much fever do you have? Where have u checked your
fever (oral, axillary, rectal). Do you have chills/night sweats?
N: Do you feel nauseated?
V: Did you throw up? (Vomiting)
T: Do u have problem in adjusting Temperature of ur surrounding?
T: Did you notice any recent weighT changes? How is your appeTite?
T: Did you Travel anywhere outside USA in recent past?
T: Do you have any physical injury anywhere? (Trauma)
T: Do you have any peT at your home?

Now I would like to ask you few questions regarding your past medical history. Is
that OK?
PAM-HUGS-FOSS
P: Did you have similar complaints in the past? / Did u have any illness in the past?
A: Are you Allergic to anything/drug? If yes, then, what kind of allergic reaction do you have?
Advice: Thank u very much for letting me know about it, I will make sure that this medication is
not included in my prescription.
M: Are you taking any medication?
H: Were you hospitalized for any medical or surgical reason before?
U: How are your urinary habits?
G: How are your bowel habits?
S: How is your sleep?
F: Now I would like to ask you few questions regarding your Family health. Is that
OK?
Are there any similar complaints in the family?

How are your family members doing?
Now I would like to ask few questions regarding women’s health, don’t feel
embarrassed I assure you that whatever we discuss will be kept confidential. Is that OK? Can I
precede?
O: Obs and gyni history

Gyni history
1. When was your last menstrual period?

2. Are your cycles regular?
3. How often do u get menses?
4. How many days do you bleed/ How long does it last?
5. How many pads do you change on a healthy day?
6. Do you notice any intermenstrual spotting?
7. When was your last Pap smear done?
8. May I know the results of Pap smear?
Obs history
1. Have you ever been preganant before?
2. Do you have any kids? If yes, then how many kids do you have?
3. How were they delivered?
4. Did you have any complication during pregnancy?
5. Did you have any miscarriage? In what trimester?
O: what do you do for your earning? Occupation. Is there any stress at work?
S: Now I would to ask few questions regarding your Social health and lifestyle.
Is that OK?
1. Do you smoke?
2. How many packs?
3. For how many years
4. Have u ever tried to stop smoking?
Counsel to stop smoking: Mr. Jones smoking causes many diseases of mouth, throat, lungs,
heart and brain. It can affect any part of body, so I suggest you to stop smoking. If you are
interested in stopping it I’ll help you and we’ll arrange a meeting for that one week later.
Challenging question: Do u think my current problem is due to smoking? Answer should be
according to illness. e.g: If the pt has presented with fever or acute diarrhea: It is less likely that
ur symptoms r due to smoking, but if the pt has presented with chest pain or chronic cough:
smoking is a strong risk factor for the symp u have presented with.
1. Do u drink alcohol?
2. What kind of alcohol?(wine, bear)
3. How many days?
CAGE questions
C: Have u ever felt a need to cut down ur drinking?
A: Have u ever felt annoyed by criticism of your drinking?
G: Have u ever felt guilty about drinking?
E: Have u ever used alcohol as an eye opener to steady your nerve or to get rid of hangover?
Is alcohol affecting ur work/daily life activities?
Counsel to stop drinking alcohol
I am sorry to ask this, Don’t mind me asking that Mr. Jones
1. Do u use any illicit drugs?

2. How do u take them? (Route of administration)
3. How often do u take them?
4. When was the last intake?
Counsel to stop taking drug illicit
Now I would like to ask few questions regarding your personal life. Don’t feel
embarrassed, I can assure you that whatever we discuss will be kept confidential. Is that OK?
Can I proceed?
S: Are you sexually active?

Who is ur partner?
Sorry to ask this, do u have any other partner? If Yes,

Are you practicing safe sex?
Do u use any form of protection like condom?
Have u ever been tested for STD’s? if yes, Were u treated for that? Were ur partner treated for
that?
Do u know ur HIV status? If yes, may I know the results? If –ve, I am glad to hear this, if +ve, I
am sorry to hear that.
If pt didn’t know HIV status, with ur permission I will arrange a test to know ur HIV status in the
later part of the day.
Physical examination
Closure: Thanks for letting me perform a brief physical examination, let me give u my
impression what might be cause of ur problem, well looking at the history and physical
examination I’ve performed I’ve a couple of possibilities in my mind, your problem can be due
to………
1. CARDIAC CASE
Chest pain, 4-5 episodes of sweating, pain radiating

Hello Mr. Jones, (shake hand) Good morning. I am Dr. David, attending
physician in this hospital/medical center. Nice to meet u. I’ll be taking care of your health
today.
CHIEF COMPLAIN: Chest pain

DDs:
MI / Angina / Pericarditis / Aortic dissection (CVS)
Pulmonary embolism / Pul: infarction / Pleuritis (Resp)
GERD / Peptic ulcer disease / Mallory Weise Tear / Oesophageal spasm / Oesophageal stricture.
(GIT)
Chostochondritis / Rib #/ Muscle strain. (Musculoskeletal)
DOPEFAAA
D: When did it start?
O: How did it start? / What were u doing at the time u had the pain?
P: How is it progressing?
Frequency
A: What makes it better?
A: What makes it worse?
LIQR
L: Can you locate your pain? Location, How long does it last?
I: On a scale of 1-10, 10 being worst pain of your life, how do you rate your pain? Intensity
Q: Can you describe your pain for me? Quality

R: Does your pain move anywhere else? Radiation
Associated symp: Do u have shortness of breath? If yes then ask DOPEFAA about
SOB.
Resp:
Do you have SOB at rest? If no, then how far can u walk before you get SOB?
Do u have SOB while lying down?
Do you wake up in the middle of the night gasping for breath?
How many pillows do u use while sleeping?
Do u have any wheeze?/cough?/runny nose?
CVS:
Do u have any racing of heart?
Do u have excessive sweating?
Do u feel nauseated?
Do u have swelling of ur ankle/feet?
Do u have rash? (Pericarditis caused by coxsackie virus)
Do u have joint pain?
Do u have lightheadedness?
Have u ever passed out? (unconscious)
Did u take flu shot recently?
GIT:
Do u have heartburn?/ water brash?/ reflux?
Stress ulcer:
Are u anxious about anything?
DVT n Pul: Embolism
Do u have any pain in ur legs while walking?
Did u have any trauma?
Then FNVTTTTT and PAM-HUGS-FOSS
Challenging questions: 1. Do u think I have heart attack?

Well Mr. Jones this is one of the possibility but still we need to exclude some other causes of
chest pain so we need to run some tests to know the exact diagnosis. Don’t worry whatever will
be the diagnosis I’ll b there all the time to help u.
2. Am I going to die?
Physical Examination:
Now I would like to perform a brief physical examination if u don’t mind.
1. Wash ur hands, make them dry and warm. I am sorry if my hands are cold. or simply wear
gloves.
2. Take permission to start examination.
3. Use respectful draping method.
4. Do not repeat painful maneuvers.
Examination components:
Neck: Look for JVD, carotid auscultation
CVS: Inspection, auscultation, palpation
Pulmonary: Auscultation, palpation, percussion
Abdominal: Auscultation, palpation, percussion
Extremities: Check peripheral pulses, check BP in both arms, look for edema or cyanosis.
Closure:
Thanks for letting me perform a brief physical examination, let me give u my impression what
might be cause of ur problem, well looking at the history and physical examination I’ve
performed I’ve a couple of possibilities in my mind, your chest pain can be due to cardiac
problem such as heart attack or angina or it may b due to acid reflux, lung problem or disorder
related to the large blood vessels in ur chest. It is crucial that we perform some tests to identify
the source of ur problem. We will start with an ECG and some blood work but more complex
tests may b needed as well. Do u have any question for me?
2. Shortness of breath SOB
Hello Mr. Jones, (shake hand) Good morning. I am Dr. David, attending physician
in this hospital/medical center. Nice to meet u. I’ll be taking care of your health today.
CHIEF COMPLAIN SOB

I can see u r in great distress. Is there anything I can do to make u more comfortable?
DDs:
Acute: CHF, Asthma, GERD, Bronchitis, Pneumonitis, FB(Foreign body)
Chronic: COPD, Bronchiectasis, Lung cancer, Tb, Interstitial lung dis

DOPEFAAA
O: How did it start?/ What were u doing at the time u had SOB?
Associated symp:
Do u have SOB at rest? If no then how far can u walk before u get SOB?
Do you have SOB while lying down?
Do u wake up at night bc of SOB?
Do u use any pillow at night bc of SOB? If yes then how many pillows?
Do u have any wheeze?/runny nose/facial pain?
Do u have any cough? If yes then DOPEFAAA and ABCOP
ABCOP
A: Do u bring up anything? (Sputum)
B: Is there any blood?
C: What is the color/consistency?
O: What is the odor?

P: Is there any pain/pus?
If u suspect Tb,
Do u have contact with any person with similar illness?
Do u have any evening rise in temperature?
Did u get ur PPD done?
Are u getting flu shots regularly?
Did u travel recently?
CVS:
Do u have any racing of heart?/ Chest pain
GIT:
Do u have any heartburn/reflux/chest pain
Panic:
Are u anxious about anything?
Questions regarding general health
FNVTTTTT
F: Fever (pneumonia) ask for chills, rigors, night sweats

V: Vomiting (Hematemesis for Mallory Weis Tear)
T: Tumor (ask appetite, recent weight changes)
T: Travel (Tb)
Then PAM-HUGS-FOSS
1. Wash ur hands, make them dry and warm or wear gloves.
Closure:
performed I’ve a couple of possibilities in my mind, your problem can be due to infection of ur
lungs/exacerbation of your previous condition/long standing smoking habits/hypersensitivity of
ur airways, but to b sure with ur permission I need to run few tests like images of ur chest,
blood work, PPD, CT chest.
Do not indulge in activities that increase ur breathlessness (smoking, strenuous exercise)

GERD: Eat 2-3 hours before going to sleep, use 2-3 pillows/prop up ur bed, that will help u
relieve ur symp.
With ur permission I’ll arrange a physiotherapist who will teach u breathing exercises.
After getting the result we will sit down together n discuss further evaluation and management.
Is that OK?
Do u have any questions?
3. Palpitation
70 years old, DM +ve, palpitation, Diaphoresis

Hello Mr. Jones, (shake hand) Good morning. I am Dr. David, attending physician in this
hospital/medical center. Nice to meet u. I’ll be taking care of your health today.
Let me make you more comfortable by putting this drape over u. Is that ok with you?
CHIEF COMPLAIN Palpitation

I’ll write few notes while we discuss if you don’t mind
DDs: CHAPATHI
C: Coffee, CVS symp

H: Hypertrophic obstructive cardiomyopathy
A: Anemia, Anorexia, Angina
P: Pheochromocytoma, Panic attacks
A: Arrhythmias
T: Thyrotoxicosis
H: Hypertension, Hyperventilation, Hypoglycemia
I: Induced by drugs
Can u exactly tell me what do u mean by palpitation?
DOPEFAAA
O: How did it start?/ What were u doing at the time u had palpitation?
F: Is it continuous/on and off? If on and off, how often does it come? How long does it last? Are
they regular/irregular? How many times do u notice them in a day?
Caffeine: Do u take coffee? If yes, how many cups/times a day?
Hypertrophic obs cardiomyopathay:

Any history of sudden death in ur family?
Avoid exertion and competitive sports?
Anemia:
Have u noticed any blood/black colored stool?
Do u have any bleeding point? (vit C def:)
Do u have any craving for ice or clay?
Do u have any numbness/tingling sensation? (vit B12 def:)
Angina:
Do u have any SOB?
Do u have any Chest pain?
Did u take flu shot recently?
Panic attacks: Do u feel anxious?
Pheochromocytoma: Do u have any headache at the time of palpitation?
Anorexia: It causes anemia and palpitation.

Do you have any weight changes?
Thyroid: Do u sweet excessively?

Do u have tremors? (shaking of hands)
Do u have any weight changes?
Hypoglycemia: Do u have skip meals?
Then FNVTTTTT and PAM-HUGS-FOS
Closure:
Advice:
Please cut down on caffeine.
Stress counsellor will help u by teaching relaxing techniques.
If on synthyroid, have regular thyroid level checkup and get the dosage accordingly.
If hypoglycemic, do not skip ur medications and have a regular diet rich in fibers n low in fat.
4. Cough
Introduction same as previous
All chronic cough pts ask about HIV status and Tb
DDs: Upper Resp tract inf, Tb, COPD, Pneumonia, Bronchogenic carcinoma, FB, GERD
DOPEFAAA
O: How did it start?
A: What makes it worse? Any part of day / season / posture?
ABCOP
A: Do u bring up anything? (Sputum)
B: Is there any blood?
C: What is the color/consistency?
O: What is the odor?
P: Is there any pain/pus?
Do u have SOB? If yes then DOPEFAA

Do u have to wake up in the middle of the night due to SOB?
Do u use any pillow/prop up ur bed to prevent SOB? If yes, how many pillows?
Do u have SOB at rest? If no, then how long do u walk to have SOB?
Do u have ankle swelling?
Do u have runny nose?
Do u have any fascial pain?
Do u have any dripping sensation in ur throat?
Do u have any soreness in ur throat?
Do u have wheeze?
Do u have water brash/heartburn/reflux?
Do u have ur PPD done?

In the medications looks for ACE inhibitors, also looks for smoking.
4. Do not repeat painful maneuvers
Examination component:
Head n Neck: Examine mouth, throat, lymph nodes
CVS: Auscultation, palpation

Extremities: Inspection
to infection that can b either bacterial or viral. This can also b due to acid reflux more
commonly known as heartburn. The chest pain you r experiencing is probably due to irritation
of ur lung membranes by infection. We r going to test ur blood and sputum and will also obtain
a chest X-ray to help us make a definitive diagnosis. Do u have any questions for me?
Advice:
Don’t indulge in activities that increase ur breathlessness.
Have meal 2-3 hours before going to bed (GERD).
Physiotherapist will teach u breathing exercise.
Use face mask when at work.
Take adequate rest and nutrition.
Use inhaler.
If u are allergic to anything, avoid it.
5. Hemoptysis
Introduction:
DDs: Pul: Tb, Pul: Edema, Bronchogenic carcinoma, Bronchitis, Pul: Embolism, Lung abscess, A-
V malformations, Pneumonia
DOPEFAAA then ABCOP… Blood, how much? Dark colored blood/fresh blood/mixed with
food particles/blood clots?
Do u have chest pain?
Do u have SOB?
Do u have wheeze?
Do u have any contacts with ill persons?
When was ur last PPD done?
How is ur appetite?
Do u have any evening rise in temperature?
Have u been restricted to any one position bc of hospitalization or travel?
Are u getting easily tired these days?
Do u have any belly pain?
CVS: Auscultation, palpation
Abdominal: Auscultation, palpation
to lung infection that can b treated with antibiotics or it may b the result from something more
serious such as cancer. We will need to obtain some blood and sputum tests as well as chest X-
ray in order to identify the source of cough. In addition we may find it necessary to conduct
more sophisticated tests in future. Do u have any questions?
6. Dysphagia
Introduction
DDs: Achalasia, FB obstruction, GERD with stricture, Esophageal carcinoma, Plummer Vinson
Syndrome, Esophagitis (HSV, CMV, drug induced), Myasthenia Gravis, Scleroderma CREST synd:,
Zenker’s Diverticulum.
dysPHAGia
Dys
P: Plummer Vinson
H: Hypothyroid
A: Achalasia
G: GIT( GERD n Zenker Divert)

ia
DOPEFAAA
Associated:
Can u locate where u feel that the food is stuck?
Do u have difficulty swallowing solids, liquids, or both? If both then which started first?
Do u have any pain while swallowing?
Do u have any water brash or heartburn?
Did u notice any food particles on ur pillow when u get up from ur bed?
Did u have any episode of choking?
Do u have any drooling?
Do u have any halitosis?
Do ur flingers change in color when they r exposed to cold? (Raynauds phenomenon)
Did u notice any skin changes? (Scleroderma)
Have u ever intentionally/accidently taken any chemical?
Do u have any drooping of eyelids?
Do u have any double vision at the end of the day?
Do u have any weakness, numbness, tingling in the body? (Stroke)
Do u have any headache and change in ur voice?
Did u taken anything intentionally/accidently which got stuck?
Did u get any food particle back into ur mouth?
Do u have any craving for ice or clay?
Then FNVTTTTT look for any travel history outside US for Chaga’s dis
PAM-HUGS-FOS
Closure:
May b due to FB
Growth in ur food pipe

Advice:
Take soft foods slowly in small amount
If problem with liquids start I/V line
GERD counselling
Investigations:
TIBC, Serum Ferritin, TSH, Plain X-ray, Barium swallow, CT chest, Endoscopy with biopsy,
Esophageal manometry, HIV
7. Belly Pain
Introduction
DDs: GOPAL-SIR
G: Gall bladder- Cholelithiasis, Cholecystitis
O: Obs/gyni- PID, Ectopic preg, Endrometrosis, Adenomyosis, Ovarian cyst/torsion
P: Pancreas- Acute Pancreatitis
L: Liver- Amoebiasis, Hyadit cyst, Hepatic congestion
S: Stomach- PUD, GERD
I: Intestine- Crohn’s dis, U.C, Diverticulitis, Mesenteric ischemia, Diverticulosis
R: Renal- RCC, Renal stone
DOPEFAAA and LIQR

FNVTTTTT and PAMHUGSFOS
H: Is there any previous history of appendectomy?/ PID?
Urinary: BC-FUN-SHIP
B: Do u have Burning sensation while passing urine? Did u ever notice Blood in urine?
C: What is the Color of ur urine?
F: How often do u pass urine? (Frequency)
U: Do u have to rush to bathroom to pass urine? (Urgency)
N: Do u have to wake up in the night to pass urine? (Nocturia)
S: How is ur Stream? Have u ever passed Stone in urine? Do u have to Strain to pass urine?
H: Do u have to wait before passing urine? (Hesitancy)
I: Did u have any urinary injury? Do u have any dribbling of urine? (Incontinence)
P: Did u notice Pus while passing urine? Do u have any Pain while passing urine?
GIT: BC-FUN-SHIP
B: How r ur Bowel habits? Did u notice Bleeding from any other sites?
C: What is the Color of ur stool? Are u passing any black Colored stool? .When was last
screening Colonoscopy done? Do u have Constipation alternating with diarrhea?
F: How Frequently do u pass stool? Does ur stool Float in the pan?
U: Do u have to rush to bathroom to pass stool? (Urgency)
N: Nadir Hotel: Did u eat any outside food?
S: Do u have to Strain while passing stool? Does ur pain have any relation with Specific food?
H: Do u take High fiber diet?
I: Do u have any sensation of Incomplete evacuation? How is ur water Intake?
P: Do u have Pain while passing stool? Do u have any belly Pain?
ABCOP in case of diarrhea
O: Occupational stress, obs: any PID

CVS: Auscultation
Pulmonary: Auscultation
Abdominal: Inspection, Auscultation, palpation, percussion, psoas sign, obturator sign, Rovsing
sign, CVA tenderness
I will perform the rectal examination and examination of ur private parts in the letter part of
the day.
Investigations:
Per Rectal examination, colonoscopy, X-ray/CT-abd and pelvis, Stool examination, CBC, PT,
APTT, AST, ALT, Bilirubin
Closure:
1. Thanks for letting me perform a brief physical examination, let me give u my impression
what might be cause of ur problem, well looking at the history and physical examination
I’ve performed I’ve a couple of possibilities in my mind, your problem can be due to a
number of disorders that can cause pain similar to what u have described. Pain of this
type is most commonly die to an ulcer, an abdominal infection or a gall stone. We will
have to run some tests to confirm the diagnosis and to rule out more serious illnesses.
These tests will include a rectal examination; an ultrasound of ur abdomen; blood tests
and possibly an upper endoscopy, which examines ur stomach by means of an optical
instrument passes through ur mouth. Once we have made the diagnosis, we will b able
to treat ur condition and help alleviate ur pain. Do u have any question?
2. Thanks for letting me perform a brief physical examination, let me give u my impression
what might be cause of ur problem, well looking at the history and physical examination
I’ve performed I’ve a couple of possibilities in my mind, your problem can be due to a
problem with ur reproductive organs such as infection in ur fallopian tube or a cyst on ur
ovary. They might also result from a complicated pregnancy, which could b indicated if
ur preg test comes +ve. Another possibility is an infection in ur appendix which could
require surgery. To know the exact diagnosis, we will need to run some tests, including
blood tests, a urinalnaysis, a preg test and CT scan of ur abdomen and pelvis. Do u have
any question?
8. Bleeding Per Rectum
DDs: CHADIF
C: Colon cancer
H: Hemorrhoids
A: Angiodysplasia
D: Diverticulosis
D: Diverticulitis
D: Dysentery
I: Inflammatory( Chron’s dis, UC)
F: Fissure in ano
DOPEFAAA
F: Do u see blood every time u pass stool? If no, how often do u pass? If yes, how much blood?
Color- Bright red/altered color? Is it mixed with stool? Do u find mucous with stool? Does it
come before/during/after you pass stool?
Associated symp: GIT symp BC-FUN-SHIP
B: How r ur Bowel habits? Did u notice Bleeding from any other sites?
C: What is the Color of ur stool? Are u passing any black Colored stool? .When was last
screening Colonoscopy done? Do u have Constipation alternating with diarrhea?
F: How Frequently do u pass stool? Does ur stool Float in the pan?
U: Do u have to rush to bathroom to pass stool? (Urgency)
N: Nadir Hotel: Did u eat any outside food?
S: Do u have to Strain while passing stool? Does ur pain have any relation with Specific food?
H: Do u take High fiber diet?
I: Do u have any sensation of Incomplete evacuation? How is ur water Intake?
P: Do u have Pain while passing stool? Do u have any belly Pain?
FNVTTTTT and PAMHUGFOS
CVS: Auscultation
Abdominal: Inspection, Auscultation, palpation, percussion.
I will perform the rectal examination and examination of ur private parts in the letter part of
the day.
Closure:
performed I’ve a couple of possibilities in my mind, your problem can be due to readily
treatable problems, such as hemorrhoids, an infection of ur colon or diverticulosis, or they may
b a sign of more serious disease such as colorectal carcinoma. It is crucial that we run some
blood tests; a stool examination; and probably a colonoscopy, which involves looking at ur
colon through a thin tube that contains a camera. Once diagnosis is made, we should b able to
treat ur problem. Do u have any questions?
9. Haematuria
Introduction:
DDs: HITTERS
H: Haematological
I: infections (Schistosomiasis, Grp: B Strep: inf)
T: Trauma
T: Tumor (RCC, Bladder cancer)
E: Exercise (Rhabdomyolysis)
R: Renal Disorders, PKD, BPH
S: Stone (Bladder, ureter)
DOPEFAA
F: Do u see blood every time u pass urine? How much blood? When did u notice blood
before/during/after/throughout passing urine?
Associated Urinay symp: BC-FUN-SHIP
B: Do u have Burning sensation while passing urine? Did u ever notice Blood in urine?
C: What is the Color of ur urine?
F: How often do u pass urine? (Frequency)
U: Do u have to rush to bathroom to pass urine? (Urgency)
N: Do u have to wake up in the night to pass urine? (Nocturia)
S: How is ur Stream? Have u ever passed Stone in urine? Do u have to Strain to pass urine?
H: Do u have to wait before passing urine? (Hesitancy)
I: Did u have any urinary injury? Do u have any dribbling of urine? (Incontinence)
P: Did u notice Pus while passing urine? Do u have any Pain while passing urine?
Then FNVTTTTT and PAMHUGSFOS
Physical examination
CVS: Auscultation
Abdominal: Auscultation, palpation, percussion, check for CVA tenderness
Closure:
performed I’ve a couple of possibilities in my mind, your problem can be due to a variety of
factors, so I would like to do a few tests to elicit an answer. First I will draw some blood and
then I will perform a genital examination as well as rectal exam to assess ur prostate. I will then
order a urine test to look for signs of infection. Depending on the results we obtain I may also
order some images studies to determine if there is stone in ur urinary tract, an anatomic
abnormality or a tumor. Do u have any question.?
Investigations:
Urinanalysis, urine cytology, C/S, BUN, S,creatinine, PSA, U/S abd, CT abd and pelvis, IVP,
Cystoscopy, CBC, ESR, Electrolytes, Hb%
10. Incontinence
Introduction:
DDs: SOUND
S: Stress---- cough, laugh, sneezing, strenuous exercise
O: Overflow--- Are u not having any feeling of sense of bladder fullness
U: Urge---- Do u have to rush to bathroom to pass urine
N: NPH (Normal pressure hydrocephalus)---- Headache, weak LL, memory problem, blurred
vision
D: DI, DM
DOPEFAAA
Associated symp:
Does it affect ur daily activities?
Does it affect ur sexual life?
Does it affect ur interpersonal relationship?
Do u use any adsorbent pads? If yes then how many?
BC-FUN-SHIP
Do u have any vaginal discharge?
Did u ever throw a fit?
How is ur thrust?
Do u have headache?
Do u have weakness in legs and arms?

Obs history:
Have u ever been pregnant before?
How many kids do u have?
What was the mode of delivery? Forceps/Spontaneous vaginal delivery/c-section

Advice:
Empty ur bladder as frequently as possible
Try to take aisle seat while u travel
Cut down ur caffeine and alcohol
I suggest u to use adsorbent pads.
With ur permission, I would like to refer u to a physiotherapist who will teach u some exercise
that can strengthen ur lower belly muscles. I will b there with u through the process.
Investigations:
Pelvic exam, cystogram, urodynamic study, urinalysis, Q-tip, CT head, RBS, HbA1.
11. Vaginal bleeding
Introduction:
DDs: A-PV-BLEED
A: Adenomyosis, Abortion
P: PID, PCOD, Perimenopause

V: Vaginal injury
B: Bleeding Diathesis
L: Leiomyoma
E: Ectopic preg
E: Endometrosis/ Endometrial cancer

D: DUB/ Hypothyroidism
DOPEFAAA
Associated symp:
Do u have any pain associated with bleeding? If yes then LIQR
Is it bright red in color?
Is it pure blood or does it contain tissue substance?
At what age did you have your first menses?
When was your last menstrual period? If greater than 5 weeks, are there any chances of being
pregnant?
Are your cycles regular?
How often do u get menses?
How many days do you bleed/ How long does it last?
How many pads do you change on a healthy day?
Do you notice any intermenstrual spotting?
When was your last Pap smear done?
May I know the results of Pap smear?
Did u have any trauma/accident?
Do u have any racing of heart/ankle swelling/passes out?
For Pelvic inflame dis: DUDI
D: Do u have any vaginal Discharge? If yes then ABCOP
U: Are there any Ulcers on ur private parts?
D: Do u feel any Dryness of ur private parts?

I: Do u have any Itching of ur private parts?
Perimenopause:
Do u have any hot flashes?
When was ur last Pap smear done? If no then order for Pap smear
Endometrosis:
Do u have pain during menses?
Do u have pain during intercourse?
Do u have pain during urination?
Do u have pain during passing stool?
Then FNVTTTTT look for symp of thyroid n tumor
Then PAMHUGSFOS look for bleeding disorder and history of multiple abortions in family
history, look for cocaine use this can cause abortion. Take a detail obs history.
Obs history
1. Have you ever been pregnant before?
2 Do you have any kids?
3 How were they delivered?
4 Did you have any complication during pregnancy?
5 Did you have any miscarriage? In what trimester?
Closure:
Your conditions appears to be emergency for me. Please don’t take anything by mouth until the
investigation results are out. My nurse will be checking for ur vitals regularly.
It can b due to complication of unknown pregnancy, abnormal hormonal level or any infection.
Advice:
Maintain genital hygiene, practice safe sex, take plenty of fluids, take adequate rest. Don’t
involve in activities that increase discomfort. Take iron and calcium supplements.
Investigations:
Urine HCG, U/S Pelvis, Cervical cultures, Endometrial biopsy, Pap smear, PT, APTT, TSH, LH,
Prolactin, Quantitative serum HCG
Challenging quest:
Am I getting old?
Ans: Aging is a natural process. Plz don’t worry we have modern treatment modalities with
which u can feel better.
12. Amenorrhea
Introduction
DDS: Pregnancy, Premature ovarian failure, Prolactinoma, PCOS, Thyroid dis, Asherman synd,
Anorexia nervosa, Perimenopause, Pills
Ask about Onset
Then DUDI for PID
Premature ovarian failure:

Do u feel hot flashes?
Do u have dryness of ur private parts?
Pregnancy:
Are there any chances of being preg?
Do u have any morning sickness (Nausea and vomiting)?
Do u have breast engorgement?

Prolactinoma:
Do u have any nipple discharge?
Do u have any vision problems?
Do u have headache?
PCOD: Did u notice any excessive hair growth in ur face?
Thyroid qust:
Anorexia nervosa: Any weight changes?
Premature ovarian failure n Perimanopause:

Do u feel hot flashes?
Do u feel dryness of ur private parts?
How is ur mood? (Depression) if good then ICE and if bad then SIGEM-CAPS
ICE
I: How is ur Interest nowadays?

C: How is ur Concentration?
E: How is ur energy level?
SIGEM-CAPS
S: How is ur sleep?
I: How is ur interest?
G: Do u feel guilty?
E: How is ur energy?
M: How is ur memory?
C: How is ur concentration?
A: How is ur appetite?
P: Psychomotor
S: Do u have suicide ideas? If yes then

I can understand that u are going through a tough phase of life. Life is a challenge, u will have
many ups and down, take it positively and whenever u get similar thoughts please call ur
beloved ones. Do u have anyone to talk when u feel low?
Pill induced:
Are u using any OCP’s?
Do u have any stress at work?
FNVTTTTT & PAMHUGSFOS

Do belly n genital exam, look for ocular movements, visual field, reflexes
Investigations:
Urine HCG, urine culture, LH, FSH, TSH, serum prolactin, U/S pelvis, blood sugar, Pap smear,
cervical culture, HIV, Hep:B, VDRL, RPR.
Challenging quest:
Do u think I am preg?
Ans: I understand ur anxiety about this unplanned preg. I suggest that u discuss this with ur
husband. As ur physician, I want to assure u that I am here to support and advise u regardless
of the decision u make. If u wish I would b happy to discuss ur options with both of u.
13. Dyspareunia
Introduction:
DDs: Vulvodynia, Vaginismus, Atrophic vaginitis, cervicitis, endometrosis, PID, Depression,
Domestic violence
DOPEFAAA, DUDI, belly pain, gyni n obs history, mood, safe at home, FNVTTTTT then
PAMHUGSFOS
14. Sexual dysfunction

Introduction:
DDS: DSP-HAT
D: DM, Drugs(beta blockers), Depression
S: Stress induced, Stroke
P: Performance anxiety, Post-MI, Pituitary(increase prolactin, decrease testosterone)
H: Hypertension
A: Atherosclerosis
T: Trauma to back
DOPEFAA
Intensity: On a scale from 0-6 with 0 being totally flaccid and 6 being just able to penetrate
how can u grade ur problem?
How is ur desire?
Do u have any problem with erection?
Have u observed any early morning erection?
Are u anxious about sex?
Who is ur partner?
Do u have any other partners? If yes then do u have this problem with all ur partners? If no
then how is ur relationship with ur partner?
Have u noticed any discharge from ur private parts?
Do u have any sores on ur private parts?
How is ur mood? If good then ICE if bad then SIGEMCAPS
Do u have any headache/vision changes?
Do u have any weakness/numbness/urinary/stool incontinence?
Do u have any pain in ur legs while walking?
Do u use Vigra?
Then FNVTTTT and PAMHUGSFOS
Examination:
CVS, CNS
Investigation:
Blood glucose, Stamp test, serum lipids, pelvic Doppler, serum testosterone, RBS
15. Sore Throat
Introduction:
DDs: Infectious Mononucleosis, Streptococcal Pharyngitis, URTI, Viral pharyngitis, Bacterial
pharyngitis, Acute HIV, GERD
DOPEFAAA
Associated symp:
Do u have any runny nose?
Do u have fascial pain?
Do u have ear pain?
Do u have ear discharge? If yes ABCOP
Do u have any swollen gland/LN/Dysphagia? If yes are they painful?
Do u have cough/SOB/chest pain?
Do u have belly pain?
Do u have rash?
Do u have any change in color of urine?
Do u have any ill contacts?
Do u have any waterbrash/heartburn/nocturnal cough?
FNVTTTT then PAMHUGFOS, ask about sexual history
Physical examination:
Exam components:
Head and Neck: Examine nose, mouth, throat, lymph nodes, checked for sinuses tenderness.
CVS: Auscultation
Skin, lymph node: Inspect for rashes, lesions, lymphadenopathy
Closure:
performed I’ve a couple of possibilities in my mind, it is likely that u have acquired the same
infection ur girlfriend had. This may b no more than a transient viral infection or it may
represent a more serious illness such as HIV. We will need to rum a few tests to help us make
the diagnosis. I recommend that we obtain an HIV test. In any case I strongly recommend using
condoms to avoid an unwanted pregnancy and to prevent STDs. Since inf mononucleosis is one
of the disease that might account for ur symp, I also recommend that u avoid contact sports bc
of possible risk of traumatic rupture of ur spleen which could b fatal. Also, since cigarette
smoking is associated with a variety of diseases I advise u to quit, we have many ways to help u
if u r interested. Do u have any questions for me?
16. Hoarseness of voice

Introduction:
DDs: Reflux Laryngitis, Cancer of vocal cords, Laryngeal carcinoma, Vocal nodule/polyp, Vocal
cord palsy (Recurrent laryngeal Nerve palsy), Hypothyroidism, Chronic laryngitis
DOPEFAAA
Associated symp:
What exactly do u mean by discomfort?
Do u notice any changes in ur voice? If yes hoarseness, if no sore throat.

Can u describe it?
Do u have exposure to cold weather or dust?
Do u have any pain while speaking?/swallowing?
Do u have any problem with high pitch and low pitch?
Do u have any cough?
Do u bring up any phlegm?
Do u have any heartburn/water brash?
Do u have any cough while eating/lying down?
Do u have cough while swallowing? (Recurrent laryngeal n palsy)
Do u have any difficulty in breathing? (Vocal cord palsy)
Do u have any pain in swallowing?
Do u have any slurring of speech?
Do u have any weakness in arms and legs?
Exam components:
HEENT: Inspect conjunctiva, mouth and throat, lymph nodes, examine thyroid gland
CVS: Auscultation
Extremities: Inspection, DTRs
Closure:
performed I’ve a couple of possibilities in my mind, your problem can be due to infection or a
growth caused by either a benign polyp or a cancer. To find out I need to do laryngoscopy
which is a procedure to view the inside of ur throat, and a CT scan of ur neck. These tests will
likely reveal the underlying problem. Since cigarette smoking is dangerous to ur health I advice
u to quit smoking. We have many ways to help u if u are interested. I also recommend that u
stop drinking as alcohol and smoking are associated with laryngeal cancer. Please don’t strain
ur voice, take warm water gargles. Do u have any other question for me?
Investigations:
Indirect laryngoscopy, CBC, ESR, X-ray neck and chest, UGE, 24 hour pH monitoring
17. Vomiting
Introduction:
DDs: Pregnancy, Bowel obstruction, Gastroenteritis, Migraine, Pyelonephritis, Chemotherapy,
Pancreatitis, Surgery (paralytic ileus/adhesions), UTI, Cholelithiasis.
VOMITING
V: Vomiting
O: Obs/Obstruction
I: Inflammation (Pancreatitis, pyelonephritis)

T: Treatment (Chemotherapy/surgery)
In: Intracranial
G: GE
DOPEFAAA and ABCOP
Associated symp:
Do u have any back pain?
Do u have any headache?
Do u feel the room is spinning around u?
Did u eat food outside?
Ask about any history of chemotherapy, ask BC-FUN-SHIP for pyelonephritis, ask about
menstrual history to exclude pregnancy.
Examination:
ENT and Abdominal
Investigations:
Urine hCG, Pelvic exam, U/S pelvis, CBC, Electrolytes, Calcium, glucose, urine analysis, urine
culture, U/S abdomen, Baseline Pap smear, Cervical culture, HIV, Hep B, VDRL
18. Loss of consciousness

Introduction:
DDs: Trauma, Hypoglycemia, Seizures, Arrhythmias, Heat exhaustion, Stroke/TIA, Orthostatic
hypotension, Hypovolemia
For all CNS cases u must ask, Is there any weakness anywhere in ur body?
HOT-ASS-V
H: Hypoglycemia, Heat exhaustion (Hypovolemia)
O: Orthostatic hypotension
T: Trauma
A: Aortic stenosis/ Arrhythmias

S: Stroke, SOL
S: Seizures, Substance induced
V: Vasovagal attack/ Vertigo
DOPEFAAA
What were u doing at that time?
Do u relate this problem to any event?
Did u loose ur consciousness before or after the fall?
Before the event:

Did u smell anything unusual (Burnt smell)? convulsive syncope
Did u have any warning signs like sound, smell, light?
Did u have racing of heart/chest pain? (Aotic stenosis)
Did u have any lightheadedness? (TIA)
Did u any excessive sweating? Hypoglycemia
Did u skip any meal before? Hypoglycemia
Did u have any spinning/ear pain? Vertigo
Did u have any trauma to head?
Have u exercised strenuously?

During the event:
Did u notice any jerky movements? If yes then how many episodes? How long does that last?
Did u have any tongue biting/frothing?
Did u pass urine or stool during the attack?
After the event:

Did u had any confusion?
Did u have any numbness/tingling/headache/nausea?
FNVTTTT then PAMHUGSFOS
Head and neck: Inspection of head n mouth, carotid auscultation and palpation, thyroid exam
CVS: Palpation, auscultation, orthostatic signs
Extremities: Palpate peripheral pulses
Neurologic: Mental status, Cranial Nerves, fundoscopic examination, motor exam, DTRS,
Cerebellar, Romberg test, gait, sensory.
Closure:
Mr. Jones I need to run some tests to determine the reason u passed out this morning, so I am
going to get a CT scan of ur head to look for bleeding or masses and I will then order some
blood tests to look for infections or electrolytes abnormalities. You mentioned that your heart
was racing before you passed out s I will ask you to wear a heart monitor for 24 hour. Doing so
is just like having constant ECG and it will allow us to detect any abnormal heart beats you
might have. We will start with these tests and then go from there. Do you have any questions
for me?
Investigations:
Blood glucose, Serum electrolytes, CBC, B.P monitoring. CT of head, MRI of brain, ECG, 2D-Echo,
Holter monitoring, EEG.
1. 50 year black male football player, single episode of unconsciousness, heavy drinker,
cocaine abuser, skip meal.
2. Same with seizures
3. Driving car, sudden loss of consciousness, hypertension
Challenging question:
My wife ask me to drive car, car I drive?
Doctor what if I pass out and never wakeup?
Did I pass out due to cocaine?
Can I go for match?
Is it the same attack as that of my brothers?
DDs: Cocaine induced, HOCM, Drug induced, TIA
19. Headache
Introduction:
DDS: Cluster headache/ cocaine, Migraine, Meningitis, Refraction headache, Tension headache,
Temporal arteritis, Trauma, Tumor (space occupying lesion), sinusitis, Subdural hematoma,
Pseudotumor cerebri, Prolactinoma
DOPEFAAA and LIQR

Associated symp:
Cluster headache:
Do u have any watering of eyes?
Do u have any runny nose?
Do u have any pain around the eyes?
Tension headache:
Do you have any stress any home/work?
Migraine:
Do u have any warning signs before the onset of headache?
Do u have any specific discomfort towards bright light?
Meningitis:
Do u have neck stiffness?
Did u have any ear discharge?
Refraction and tumor:
Do u have any vision changes?
Temporal arteritis:
Do u have any jaw pain while chewing?
Trauma:
Do u have any head trauma?
Sinusitis:
Do u have any fascial pain?
CNS:
Do u have any weakness in your arms/legs? (Stroke motor)
Do u have any tingling or numbness? (Stroke sensory)

Do u have any difficulty in swallowing? (Stroke Cranial N involvement)
Do u have any slurring of speech? (Stroke or TIA)
Do u have any changes in vision? (Prolactinoma)
Do u have any urinary or stool incontinence? (Stroke)
FNVTTTT and PAMHUGSFOS ask about trauma, tumor, OCPs, occupational stress
Exam components:
HEENT: Palpate head, facial sinuses, temporomandibular joint, do fundoscopic exam, inspect
nose, mouth, teeth and throat
Neck: Inspect, palpation
CVS: Auscultation
Neurological: Cranial nerves, muscle strength, DTRs.
Closure:
performed I’ve a couple of possibilities in my mind, your problem can be due to a migraine
headache so the first thing I will do is prescribe some medications that will alleviate your pain.
To ensure that there isn’t something else going on however I would like to get a CT scan of your
head to rule out a mass or vascular problem as a cause of your headache. A blood test may also
show if you have problem other than migraine. Do u have any other question for me?
Investigations:
CBC, ESR, Serum electrolytes, CT, MRI of brain, CSF analysis
20. Fatigue
Introduction:
DDs: HOD-CAMP
H: Hypothyroid, HIV
O: Obstructive sleep apnea/Occult malignancy
D: DM/Depression/Domestic violence
C: Caregiver fatigue/Compassion fatigue

A: Anemia/ Adjustment disorder
M: Myasthenia gravis
P: Post traumatic stress disorder
DOPEFAAA then HOD-CAMP qustions

Associated symp:
Hypothyroid:
Do u have any problem in adjusting with surrounding temperature?
Do u have any constipation?
Do u have any hair fall?
Do u have any hoarseness of voice?
Do u have any dryness of skin?
Obstructive sleep apnea:

Did anyone notice you snoring at night?
Do u feel refreshed after waking in the morning?

Do u feel tired and sleepy during day?
Malignancy, HIV, Hypothyroid:

Do u have any recent weight changes?
How is your appetite?
Depression:
How is your mood? If good then ICE and if bad then SIGEMCAPS
DM:
Do u have any increase in thirst/hunger?
Do u have any increase in frequency of urination?
Domestic violence:
Are u physically or emotionally hurt or abused by anyone?
Are u feeling safe/are u afraid at home?
Anemia:
Do u have any racing of heart? SOB?
Do u have any bleeding point?
Adjustment disorder:
Do u have any stress at work or home?
Myasthenia Gravis:
Did u notice any drooping of eyelids?
Did u notice any double vision?
Did u notice increased fatigue at the end of the day?

PTSD:
Do u have any nightmare/flashback of these events?
FNVTTTT and PAMHUGSFOS
Exam components:
Head and neck: Inspect conjunctiva, mouth and throat, lymph nodes, examine thyroid
CVS: Auscultation
Extremities: Inspection, check DTRs
Closure:
performed I’ve a couple of possibilities in my mind, your problem can be due to your lifestyle bc
its stressful lately and my suspicion is that you may b clinically depressed. Before I make a
definitive diagnosis, however I would like to order some blood tests including one for HIV as
you have risk factors for sexually transmitted diseases. Depending on the results of these tests I
may also ask you to participate in a sleep study in which doctors can observe how you breath
while you are sleeping. Once we have completed these tests we should have a better idea of
what is causing your fatigue. In the meantime I strongly recommend that you quit smoking,
exercise regularly and participate in activities that you find relaxing. I would also like you to
promise me that if you feel like hurting yourself, you will call someone who can help you or go
immediately to an emergency department. Do u have any questions for me?
21. Hearing loss
Introduction:
DDs: LMNOP- FIT
L: Labyrinthitis
M: Meneirre’s Dis
N: Noice induced, acoustic Neuroma
O: Otosclerosis, Otitis media, Ototoxic drugs
P: Presbycusis, perilymphatic fistula
F: Foreign body
I: Impacted wax
T: Trauma
Introduction: Hello Mr. Jones………no response

My nurse told me that u have a problem with your hearing. Am I audible to you? Do you want
me to come close to you? May I know in which ear you have problem? Can u hear me from that
position?
If both ears….. Ohh I am sorry
DOPEFAAAA then JUST questions
JUST
Do u hear words Jumbled/distorted?
Do u have any problem Understanding the speech?

Is ur problem same with all Sounds/ Some sounds? Can u locate the Source of sound? Do u
have any nasal Stiffness? Does it affect your life Style?
Did u try any Treatment for your hearing loss?
Associated symp:
Otitis media:
Do u have any ear pain? If yes then LIQR
Do u have any ear discharge? If yes then ABCOP
Labyrinthitis:
Do u have any imbalance/runny nose/sore throat/cough?
Do u have any ringing sensation in your ear?
Do u have fullness of ur ears? (Wax)
Do u have any feeling of room spinning around you?
Have u ever been exposed to loud noise? (Noise induced)
Acoustic neuroma:
Do u have any facial pain/facial weakness?
Do u have any visual problem?
Foreign body:
Did u insert any FB either accidently/intentionally into ur ear?
Trauma:
Have u ever had a trauma?
FNVTTTT ask about air travel, scuba diving

In drugs look for loop diuretics and other ototoxic drugs
PAMHUGSFOS
Exam component:
HEENT: Tested hearing by speaking with back turned, inspect sinuses, nose, mouth, throat, do
fundoscopic exame, and otoscopy, assess hearing with Rinne, Weber and Whisper test.
CVS and pulmonary: Auscultation
Neurologic: Cranial nerves, sensation, motor, reflexes, cerebellar—finger to nose, heel to shin.
Closure:
Mr. Jones I know that u are concerned about ur problem. I can confirm that u have some
hearing loss. I would like to rum several tests, including some blood tests. I would like u to stop
taking aspirin bc this may b contributing to ur hearing loss. I will refer you to an audiometrist
who will assess u for a hearing aid. Do u have any questions for me?
Challenging question:
Am I going to b deaf?
Ans: I understand ur concern it is obvious from my examination that u have hearing loss but it
could also be due to some reversible causes, treating them may restore ur hearing. For that I
need to rule out irreversible causes?
Investigations:
Audiometry, Tympanometry, CT head, Brainstem audiometry evoked potential, CBC, ESR, VDRL
22. Dizziness
Introduction:
DDs: Meningitis, Orthostatic hypotension, BPPV, Labyrinthitis, Acoustic neuroma,

Perilymphatic fistula, Hypoglycemia, Hyperthyroidism
DOPEFAAA ask about any special time and position of its occurrence
Associated symp: DiSC-MELAP
D: What exactly do u mean by dizziness?
S: Have u Skipped any meal?/ exercise Strenuously?
C: Chest quest…. Chest pain/SOB/racing of heart?
M: Meneirr’s dis… Do u have any problem with hearing?

Do u have any ringing sensation in ear?
Do u have any sense of room spinning around u?
E: Do u have ear pain? / discharge?
L: Labyrinthitis…. Do u have runny nose/sore throat/cough?
A: Acoustic neuroma: Do u have headache, vision prob, facial weakness?
P: Do u have any Procedure done on ur ear recently?

Do u have any weakness/tingling/numbness anywhere?
Exam components:
HEENT: Inspect for nystagmus, fundoscopic exam, otoscopy, assess hearing, Rinne’s and Weber,
inspect mouth and throat
CVS: Auscultation, Orthostatic hypotension
Neurologic: Cranial Nerves, Motor exam, DTRs, gait, Romberg sign, Tilt test
Closure:
performed I’ve a couple of possibilities in my mind, your problem can be due to a problem in ur
ears or brain or it may result from low blood pressure. We will have to run some tests to
pinpoint the source of ur symp. These may include blood tests, hearing evaluation and MRI of
ur brain. Until we find the cause of ur problem it is important that u r careful when u stand up
quickly or walk unaccompanied and u should b sure to make use of hand railing whenever
possible. Do carry ID cards with phone no of ur beloved ones. Avoid high altitude. Do u have
any questions for me?
Investigations:
VDRL, PRP, Vital signs, Audiogram, CBC, Electrolytes, Blood sugar, CT, MRI of brain
23. Insomnia
Introduction:
DDs: GMC-PROUD
G: Generalized anxiety disorder, GERD
M: Menopause/Medication
C: Circadian rhythm, Coffee
P: PTSD, hyperthyroid
R: Restless leg synd
O: Obstructive sleep apnea
U: UTI, BPH
D: Depression, DM, Drugs
DOPEFAAAA
I need to ask u few questions about ur sleep patterns. Is that Ok with U?
Do u have any problem falling asleep?
Do u have any problem staying asleep?
Do u wake up early in the morning?
Falling asleep:
When do u usually go to bed?
How much time do u take to fall asleep?
What do u do before u go to bed?
Do u exercise?
Do u take excessive alcohol/coffee before going to bed?
Do u watch TV while lying on the bed?
Do u smoke?
Staying asleep:
How many hours do u sleep?
How many times do u wake up in the middle of the night?
What do u think is causing this?
Do u wake up to urinate many times in night?

Anxiety: Are u anxious about anything?
GERD: Do u have water brash/nocturnal cough/acid reflux?
Menopause: Do u have any hot flashes?
Circadian rhythm: Do u have any recent changes in ur work shift?
PTSD: Do u get any nightmare/flash backs of those events?
Restless leg synd: Does anyone notice frequent movements of ur legs during ur sleep?
Obstructive sleep apnea:

Do u feel sleepy during day time?
Do u feel refreshed after u wake up early in the morning?
Do u feel sleepy during the day?
Did anyone notice u snoring when u sleep?
Depression:
How is ur mood? If good ICE and if bad then SIGEMCAPS
Examination:
MMSE+ Cranial nerves + MRSP
MMSE: Orientation, memory, concentration, judgment
Orientation: Time, Place and Person

What is ur full name?
Do u know where are u now?
What time of the day is it?

Memory: Remote, Recent, Immediate
What is ur date of birth?
What did u have in lunch yesterday?
I will tell u names of 3 things, please repeat them for me
Concentration: Can u spell the word BOOK backwards for me?
Judgment: What do u do when u see a cloth catching fire?
Investigations:
Polysomnography, mental status, TSH, CBC, ECG, EEG, Urine toxicology
Advice:
Please maintain a sleep diary, follow regular bed time and wake time. Do not exercise in early
evenings. Do not take coffee/alcohol. Do not smoke before going to bed. Avoid watching TV on
bed. Avoid day time naps.
24. Confusion/Forgetfulness
Introduction:
DDs: VANISHED
V: Vascular dementia, Vit B12 def
A: Alzhemier’s dis
N: Normal Pressure Hydrocephalus, Neurosyphilis

I: Intracranial tumors/Infections
H: Hypothyroidism, Hypoglycemia
E: Encephalitis, Electrolyte imbalance
D: Depression, DM, Drugs

Other: Wernicke’s encephalopathy, Chronic subdural hematoma, Creutzfeld Jacob dis
DOPEFAAA
Are there anything that are difficult to remember?
Do u recognize or does anyone tell u about it?
If memory is decreased. DEATH- SHAFT
D: Do u have problem with dressing?
E: Do u have problem in Eating?
A: Do u have problem in going Around/finding ur home?
T: Do u have problem in Toileting?
H: Do u have problem in maintaining Hygiene?
S: Do u have problem in shopping?
H: Do u have problem in house keeping?
A: Do u have problem in maintaining ur Account?
F: Do u have problem in Food (Cooking)?
T: Do u have problem in Travel (Driving)?
Cranial Nerves:
Do u have difficulty in speaking/swallowing?
Do u have any problem with vision?
Do u have any headache/neck stiffness? ( Meningitis)
Motor: Do u have any weakness in body?
Sub-dural hematoma: Do u have any head trauma?
Sensory and vit B12 def: Do u have any tingling/numbness?
ANS: Do u have any urinary/stool pass without ur notice?

Do u have any problem with ur walking? (Normal press: Hydrocephalus)
Did you skip your meal?
Have u ever passed out?
Did u ever suffered from a stroke?
To whom do u live with?
Is there anyone to take care of u?
How in ur mood? If good then ICE and if bad then SIGEMCAPS

I want to talk to ur family members to better know ur problem
Exam components:
Eye exam: Inspect pupil, fundus
Neck exam: Carotid auscultation
CVS: Auscultation, Orthostatic vital signs

Abdominal: Palpation
Neurologic: Mini mental examination, Cranial nerves, motor exam, DTRs, gait, Romberg sign,
sensory exam.
Closure:
performed I’ve a couple of possibilities in my mind, your problem can be due to a number of
disorders that can affect the brain many of which are treatable. We need to run some tests to
identify the cause of ur problem. I would also like to ask ur permission to speak with ur family.
They can help me with ur diagnosis and I can answer any questions they might have about what
to assess at home supervision and safety measures. The social workers will inform u of
resources that are available in the community to help u. if u would like I can remain in close
contact with u and ur family to provide additional help and support. Do u have any quest for
me?
Investigations: CT,MRI of brain, LP for CSF analysis, CBC, Serum B12, VDRL, TSH, Blood
sugar, ECG, Echo.
Advice:
Keep things well organized in ur room, maintain a diary listing ur activities, do not go outside
alone, whenever u go outside carry ID with contact no’s of ur loved ones. Take time for
pleasurable activities.
25. Auditory Hallucination

DDs: BANDS
B: Brief psychotic disorder <1 month

A: Adjustment disorder
N: Narcolepsy
D: Drug induced
S: Schizophrenia >6 Months, Schizophreniform 1-6 months, Seizures, Schizoaffective

Mr. Jones my nurse told me that u are hearing voices. Please don’t hear them. They are
imaginary. Please concentrate on me. I am here to help u. if u share ur problem with me, I can
help u out. I assure u that everything we discuss will be kept confidential.
To interrupt the SP:
Excuse me Mr. Jones I am sorry to interrupt u. I know these things are bothering u. I need to
focus completely on ur present situations. Please don’t concentrate on them. Try to
concentrate on me.
I understand that u are going through a tough phase, we will definitely work on it together
Do u hear those voices even when u close ur ears?
Do u think voices are controlling u?
DOPEFAAA
Auditory Hallucination:
How is it affecting ur daily activities?
How many voices do u hear?
Where do u think they are coming from?
Are u familiar with those voices?
What do they say?
Visual:
Do u see something that other’s don’t?
What do u see?
How long u have been this problem?
Olfactory:
Do u smell anything that others don’t?
Sensory:
Do u feel anything crawling on ur body?
Suicidal ideas:
Did u ever think of hurting u/others?
Do u have any pills/gun at home?
Delusion:
Do u hold belief that others find it odd?
Mania:
Do u feel elated?
Depression:
How in ur mood? If good ICE and if bad then SIGEMCAPS
Relation:
How is ur relationship with the family?
Are they helpful?
Do u have anyone to share ur feelings with?
Do u have weakness/numbness/tingling/incontinence/slurring of speech/headache?
Examination:
MMSE and CNS
Investigations:
Urine toxicology, CT,MRI of brain, CBC, ESR, Electrolytes, BUN, Serum creatinine, ALT/AST/ALP
Challenging question: Am I going to mad?

Mr. Jones I can understand ur apprehension, hearing voices doesn’t mean that we r going mad.
I have seen many cases of this kind who r doing well now but to be sure of the diagnosis I need
to run down some tests. Please don’t worry, whatever may b the diagnosis I am here to help u
out and give u the best treatment options available at our hospital.
26. Diabetes Mellitus….Follow up

Well Mr. Jones I am glad that u are here. I appreciate that you are taking good care of ur health.
How can I help u?
Mr. Jones, Dr. I have came for refill my medicines.
I am here to refill, I am glad to help u. Before I refill ur medications I need to ask u some
questions and do a brief physical examination.
When were u first diagnosed?
May I know what medications are u on?
Are u compliant with ur medications?
When was ur last doctor visit?
May I know the result?
Do u check ur glucose levels regularly at home? May I know the readings?
Retinopathy:
Do u get ur eye checkups done regularly?
When was the last checkup done?
Do u have blurring of vision?
CNS:
Do u have any numbness/weakness/tingling sensation?
Do u have problem controlling ur urine or stool?
Atheroscelerosis:
Do u have any chest pain/excessive sweating/lightheadedness/belly pain?
Do u wakeup at nights? If yes, how many times? Is this disturbing ur sleep?
Do u have any burning micturition?
Do u have any ulcers and recurrent injury to ur legs?
Do u have any early morning erections?

Exam components:
Eye exam: Fundoscopic exam
Neck: Carotid auscultation
CVS: Palpation, auscultation
Extremities: Inspect feet, peripheral pulses
Neurologic: DTRs, Babinski sign, sensation, motor
Closure:
Mr. Jones the palpitation and sweating u have are most likely due to episodes of low blood
sugar, which may have resulted from a higher than normal dose of insulin or from skipping or
delaying meals. The numbness u describe in ur feet is probably related to the effects of
diabetes on ur nervous system, better control of ur blood sugar may help improve this problem.
Many factors, including diabetes can cause the erection difficulties u describe. I will need to
perform an examination of ur genital area and run some blood tests, and at some point we may
also need to conduct some more complex tests to identify the cause of ur problem. Do u have
Advice:
Regular eye checkup, take small frequent meals, please don’t skip meals. Use soft heel pad
shoes, don’t injure urself, if injured take proper care as early as possible. Take diet low in salt,
carb and fat, rich fibers, exercise regularly.
27. Back pain

Introduction:
DDs: in Male, Lumber disc herniation, Lumber muscle strain, Lumber spinal stenosis,
Osteoporosis/vertebral fractures, Prostate cancer mets, UTI’s. in Female: Secondaries in spine,
Lumber disc herniation, Vertebral compression fracture, Osteoporotic compression fracture,
Lumber spinal muscle sprain, Paraspinal muscle sprain, Lumber spinal stenosis, Lumber
spondylotis.
DOPEFAAA and LIQR

Associated:
Did u have any trauma?
Did u have any vigorous exercise?
Did u carry any heavy weights?

Motor: Do u have any weakness anywhere in ur body?
Sensory: Do u have numbness, tingling or pain elsewhere in ur body?
Autonomic: How u ur urinary/bowel habits?
Multiple Myeloma:
Do u have constipation?
Do u have racing of heart?
Do u have headache?
FNVTTTT ask about tumor
PAM ask about steroids
HUGS ask about disturbances due to lying down position, UTI, kidney stone, BPH (BC-FUN-
SHIP)
FOS ask about menopause, IUDs, erection/ejaculation problem
Exam components:
Back exam: Inspection, palpation, range of motion
Extremities: Inspection, palpation of peripheral pulses, hip exam
Neurologic: Motor, DTRs, Babinki sign, gait, sensory
Closure:
performed I’ve a couple of possibilities in my mind, I am concerned about ur difficulty urinating
so I would like to do a rectal exam and assess ur prostate for benign growths or cancer. I would
also like to run some blood tests and order a X-ray and possibly an MRI of ur back so that I can
better determine the cause of ur pain. In the meantime as we discussed I will write a note a ur
employer requesting that u b given only light duties while u are at work. Do u have any
questions for me?
Advice:
Don’t strain ur back, take adequate rest, take vitD and Calcium supplements, bend at knee
instead of back while picking objects [Demonstrate and explain ROM exercise]. Once results are
out my therapist will teach u exercise to increase range of movements or ur back and
strengthens ur back muscles.
Investigations:
Rectal exam, X-ray/MRI, PSA, Serum and urinary protein electrophoresis, BUN, Serum.
creatinine, CBC, Serum Calcium.
28. Calf pain (DVT)

Introduction:
DDs: DVT, Cellulitis, Myositis, Ruptured Baker’s cyst, Hematoma, Rupture of medial head of
gastrocnemius muscle, Spasm due to injury or sprain, claudication
DOPEFAAA and LIQR

Associated symp:
RSSW
R: Redness
S: Swelling
S: Stiffness
W: Warm
CITRUS
C: Crepitus
I: Infections
T: Tick bite/trauma
R: Rash
U: Ulcer genital
S: Scleroderma
Rubor: Did u notice any redness in ur legs?
Calor: Do u have the sensation of warmth in ur legs?
Tumor: Do u have any swelling in ur legs?
Dolor: Loss of function… Are u able to move ur knee?
DVT:
Did u notice any enlarged veins in ur legs? (Vericose V)
Do u have any chest pain/cough? (Pul: Embolism)
Do u have any bleeding point?
Do u have any racing of heart?
Claudication: Does ur pain increased by walking?
FNVTTTT ask about trauma and travel

PAMHUGSFOS ask about OCPs use, orthopaedic surg, smoking, occupation, bleeding
disorder
Exam components:
CVS/Pulmonary: Inspection, auscultation, palpation, compared pulses (femoral, popliteal,
dorsal pedis) on both sides
Joint exam: Inspect, palpation, range of motion (knee, ankle, hip joint on both sides)
Extremities: Inspection, palpation, check for Homan sign
Neurologic: Sensory and motor
Closure:
Mrs. Jones on the basis of ur history and my physical exam I believe it is possible that u had a
blood clot. However we will also look for other possible causes of ur symp such as an infection
or a ruptured cyst. We will b running few blood tests as well as some imaging studies that
should help us make a final diagnosis. If ur test results show a clot we will start u on blood
thinners which should prevent further complications such as the possibility of a clot travelling
to ur legs. Do u have any questions for me?
Advice:
Avoid immobilization for long period of time, try to move in place and perhaps take a short
walk, if u are on OCPs please stop using them. Studies have shown that obesity increase risk of
having a clot so I suggest that u exercise regularly and manage ur diet.
Investigations:
Doppler U/S, D-dimer, Hypercoagulability tests, CBC with differential count, CPK and myoglobin
level, CT venography, MRI
29. Knee pain
DDs: GOT-GPRS
G: Gout
O: Osteoarthritis
T: Trauma
G: Gonococcal arthritis
P: Pseudogout/psoriatic arthritis
R: Rheumatoid Arthritis/ Rheumatic fever
S: Septic arthritis/ SLE
DOPEFAAA and LIQR
RSSW and CITRUS

Do u have joint stiffness in the morning? If yes then ask about duration
Do u have photosensitivity?
Do u have any oral ulcers?
Do u have any hair loss?
Do u have any chest pain/ palpitation/ SOB/ cough?
Do u have any seizure/ weakness/ numbness?
Exam component:
Mouth exam: Inspection
Musculoskeletal: Inspection and palpation (compare both knees including range of motion),
examine other joints (shoulder, elbow, wrist, hands, fingers, hips, ankles)
Hair and skin: Inspection
CV: Auscultation
Closure:
performed I’ve a couple of possibilities in my mind, your problem can be due to diseases like
gout, an infection or RA. To find our I would like to draw fluid from ur knee and then draw some
blood. Sometimes infections from the pelvis can spread to other parts of ur body such as ur
knee and for that reason I would also like to do a pelvic exam. These tests will likely reveal
source of ur pain. You mention earlier that u don’t always use condoms. I know condoms may b
difficult to use regularly but they are important in helping to control spread of STDs. Do u have
Investigations:
X-ray knee, MRI, Arthrocentesis, RF, Cervical cultures, ANA, CBC, ESR, Serum uric acid.
30. Ankle pain

DDs: Retrocalcaneal bursitis, Calcaneal compression fractures, Tarsal tunnel synd, Ankle
sprain, Plantar fasciitis, Medial malleolar fracture, Lateral malleolar fracture
Same questions and examinations as that of above.

31. Shoulder pain
DDs: Subacromial bursitis, Recurrent shoulder dislocation, Fracture neck of humerus,
Supraspinatous tendinitis, Rotator cuff tear.
Same questions and exam as that of above
32. Neck pain

DDs: Cervical spondylosis, Cervical spinal stenosis, Cervical disk herniation, RA,
Radiculopathy, Muscular strain
Same questions and exam as that of above
33. Hip pain

DDs: Trochenteric bursitis, OA, Septic arthritis, AVN, Ligament sprain/strain, Fracture neck of
femur, Reactive arthritis, RA
Same questions and exame as that of above

34. Elbow pain
DDs: Lateral epicondylitis (tennis elbow), Medial epicondylitis (golf elbow), Fracture of
radius/ulna, Dislocation, Ligament sprain
35. Fever with diarrhea

Phone case:
Introduction:
Hello, I am Dr. David attending pediatrician in this medical center. May I know to whom am I
speaking to? Yes Dr. I am Mrs. Jones. Ok Mrs. Jones How can I help u?
My child has……………Presenting complain
Ohh, I am sorry to listen about ur child’s problem. I will try my level best to help him/her in this
regard. For that I need to ask u few questions. Do u mind if I make a short note while we
discuss..
If there is a pause in the conversation please understand that I am making a note.
What is ur child’s name?
How he is related to u?
How old is ur child?
Where is ur child now?
To whom is the baby staying with?
Can u tell me more about ur child’s problem?
DDs: Rotavirus, Bacterial diarrhea, Malabsorption, Intussusception, UTI, Sepsis

Diarrhea/vomiting.
ON-CALL-IDIOT
O: Onset
N: Number
C: Cry/Cough/Consistency
A: Associated symp (Ear discharge, Ear pulling, Watering of eye, Runny nose, Cough, Difficulty
in breathing/swallowing, Rash, Threw up, Cry while passing urine/stool, Bowel movements, Any
dry mouth, Any sunken eyes, Any belly distension, Any sunken soft spot on his head,
Dull/playful, How is he sucking/feeding)
L: Listlessness
L: Liquid (urine) intake and out put
I: Immunization
D: Diet/Dehydration/Daycare/Doctor visit
I: Infection in family/ ill contacts
O: ORS
T: Travel
Ask DOPEFAAA about fever
Ask ON-CALL-IDIOT, DOPEFAA and ABCOP about diarrhea
A: Amount
B: Blood or worm
C: Color/Consistency/Contact with sick persons

O: odor
P: Pus/pain/wet diaPers.
Fever: Did u measure the temperature? If yes Where did u measure? (axilla, rectum, oral),
What was reading?
Is it high grade or low grade?
Does he have chills?
Does he shake his body in fever?
Avoid asking same questions in these formulas
FNV
Then BINDERS
B: Birth history/ Breast feeding
I: Immunization
N: Nutrition
D: Daycare/ Dehydration/ Doctor visit
E: Ear/ Energy/ mouth and nose
R: Rash
S: SOB/ Sleep
Birth history: Any history of STDs to her mother?
During pregnancy:
Any exposure to alcohol, smoking, drugs?
Did u went for regular antenatal checkup?

Any medical illness or fever?
Do u got ultrasonography in each checkup?
Did u got any medication like Multi vitamins/Vaccination?
During delivery:
Was ur baby born preterm, interm, post term or delayed labor?
What was the mode of deliver? Was it normal vaginal delivery or c-section? Was any
complication during pregnancy?
When did baby cried after birth?
How did u cut his cord?
What is the blood group of child’s father and mother?
After Delivery:
Any infection after delivery?
When did u start breast feeding?
How was the baby after birth?
When was his first bowel movement/urine passed?
Immunization:
Are ur child’s vaccinations up to date?
What and when was ur child’s last immunization done?
Nutrition:
Did u breast feed the baby or not?
When did u start the supplementary foods?
How is his appetite?
Did u gave him any fluids after his diarrhea?
Any oral rehydration solution?

Developmental:
Is ur child’s growth and development on par with other pears of his age?
Daycare:
Does he go any day care?
Are there any sick contacts at the daycare?
Doctor visit:
When was his last Drs. visit? If yes then appreciate, if no then advice
ERS:
is there anyone smoker around the child? If yes then Do they smoke around child?
Is ur child safe at home? (child safety) Break the confidentiality and involve child safety team.
How is the relation of father with baby?
PAM-HUGS-F
Mrs. Jones from the information u have given me, I am concerned that ur child may be
dehydrated due to…….. it is very hard for me to assess her over the telephone and I don’t want
to jeopardize her health in any way, so I would like u to bring in ur child to medical center, we
will then proceed accordingly. Meanwhile I advice u to give her plenty of fluids which can
correct her dehydration to certain extent.
Challenging ques:
I can understand ur concern towards ur child’s health. Ur child is in safe hands we have an
excellent ICU here who will take care of ur child.
Ur emotional stability is very important for ur child’s health. Please bear with me. Once I am
done with my questionnaire, I will attend ur child personally.
Investigation:
Rotavirus enzyme immunoassay, Electrolytes, Stool leucocytes/culture/ova/cyst, Parasites, pH,
Urine analysis, urine for c/s, Abdominal x-ray, Blood cultures.
36. Jaundice
Phone case:
discuss..
DDs: Early onset <1 week
Physiologic jaundice, Breast feeding jaundice, ABO/Rh incompatibility, Neonatal sepsis,

Cephalhematoma, Polycythemia, Familial neonatal hyperbilirubinemia
Late onset:
Breast milk jaundice, Biliary atresia, Metabolic (Hypothyroidism, Galactosemia, G6PD def,
Hereditary hemolytic anemia)
Chief complain: Discoloration
Color changes:
When did u first notice jaundice, < 24 hours, after 7 days, after 14 days?
Does it reappears after 7 days?

Are the skin and eyes both turning yellow?
How it is progressing?
Does the skin appear deep yellow/orange?
Urine:
What is the color of his urine? Any change?
How often does he pass urine?
How often do u change his diapers?
When did he last pass his urine?
Does he cry while passing urine?
Stool:
Did he pass any stool?
What is the color of the stool?/Consistency?
How often does he pass stool?
Any blood or worms in stool?
Vomitus:
Did u throw up? If yes then ABCOP
Did u notice any belly distension?
Breast feed jaundice:

When did u first start breast feeding?
Did u breast feed/bottle feed him?
How often do u feed him?
Is he sucking well?
ABO incompatibility:
What is ur blood group?
What is the blood group of ur baby?
Did u ever become pregnant before?
Did u have any miscarriage? (Erythroblastosis Fetalis)
FNV, BIND(ERS) and PAM-HUGS-F
Closure:
Mr. Jones as per the information provided by u I am considering a possibility of physiologic
jaundice/natural jaundice. It usually peaks on day 4 or 5 and then gradually disappears over 1-2
weeks. However there are certain other possibilities like jaundice of breast feeding or some
other pathological conditions or birth defects. I do suggest u to bring ur child to the medical
center for further evaluation. Meanwhile I will suggest u to feed ur baby every 1-2 hours during
the day and don’t let him sleep more than 4 hours at night without feeding.
Hope u understood whatever we discussed today.
Do u have any questions/concerns?
Other than this if he has any signs like temperature of 104 F, any bluish discoloration of the
body, sign and symp, please call 911/come to hospital immediately.
Investigations:
CBC, Blood glucose, Serum Bilirubin (Total, Indirect, Direct), Direct Coomb’s, CRP, Titers for
CMV, Toxoplasmosis and Rubella.
37. Snapping (Being irritable for silly things)
DDs: MH-GAS
M: Menopause
H: Hyperthyroid (case at houston)
G: Generalised anxiety disorder
A: Anemia
S: Stress
DOPEFAAA
Is it affecting ur daily activities?
Is it affecting ur interpersonal relationship?
Do u have any problem adjusting to temperature?
Menopause:
Do u feel hotflashes/vaginal dryness?
Ask Hyperthyroid questions
GAD:
Are you anxious about anything?
Stress:
Do you have stress?

Tape for private parts:
I can understand that discussing about ur private problem is difficult for u. Please treat me as
ur friend and feel free to discuss ur problem. I assure u that whatever we discuss will b kept
confidential.
The information u give me may provide a very important part of my diagnosis. So please open
up.
38. Picky Eaters

DDs: Habitual eating disorder, Lead poisoning, Iron def anemia, Low fiber diet, Parasitic
infestations, Hypothyroidism, Oppositional defiant disorder, ADHD.
Phone case:
discuss..

Why do u think ur child is a picky eater?
DOPEF
Behavior:
Have u ever punished/rewarded ur child to alter his eating behavior?
Does he watches TV while mealtime?
Doe he follow his schedule of meals?
Does he often drink high calorie drink like soda?
Do u offer any desserts with regular meal?
Bowel:
Does he often have belly pain?
Any problem with bowel movements? If yes How many times a week does he have his bowel
movements?
How are the stools?
ABCOP
Doe he strain while passing stool?
Toilet training:
When did he start sitting on the toilet?
How long does he sit on the toilet?
Does he resist toilet training?
Does he avoid toilet training because of activities such as playing?
Family:
How many children do u have?
How much time do u spent with them?

Who takes care when u are out working?
Does he go to any daycare center?
Does he have any ill contacts there?
BINDERS, FNV, PAM-HUGS-F
Closure:
According to the information provided by u, I feel that ur son is probably passing through a
normal phase of growth. It is a common problem in this age group. Fortunately it responds to a
few behavioral changes.
First of all I would suggest u to follow a set schedule and offer him a variety of foods at meal
time.
Discourage high calorie drinks bw the meals.
Next important thing is environment at meal time, any argument or watching TV should b
avoided at same time.
Regarding the constipation I would suggest u to provide him high fiber diet like cereals and
vegetables. Encourage him to follow a schedule to use the toilet.
However I need to examine him/her personally and rum down few tests before I make my
diagnosis and give u my final opinion. Do u have any questions for
Me?
Does that sounds good to u?
Investigations:
Physical exam, CBC, x-ray chest, Serum electrolytes, Serum lead level, TSH, T3, T4, TIBC, Serum
iron, Ferritin.
39. Stridor
DDs: F-CLEAR
F: Foreign body obstruction
C: Croup
L: Laryngitis/Laryngomalacia
E: Epiglottitis
A: Angioedema
R: Reteropharyngeal abscess
Phone case:
Introduction:
I can understand ur concern towards ur child’s health. Ur child is in safe hands, we have an
excellent ICU support here, who will take care of him. Ur emotional stability is very important
for ur child’s health. Please bear with me, for that I need to ask u few questions. Once I finish
asking u, I will attend ur child.
May I know why is he in ICU?
How old is he?
How is he related to u?
DOPEFAAA
Is this sound consistently there/does it come and go?
What was he doing when it started?
Associated quest
BIG-DACH
B: When it is better heard?/Breathlessness/Bluish discoloration.
I: Did u intervene in any way? H/O intubation

G: Guraka—Does he snore while sleeping?
D: Any drooling/difficulty in swallowing?
A: Allergy
C: How is his Cry, cough, chocking?
H: Hoarseness
BINDERS, FNV, PAMHUGSF
Closure:
performed I’ve a couple of possibilities in my mind, your problem can be due to foreign body
aspiration. However possibilities of some infections causing the same problem might not be
ruled out. I feel that she needs an emergency medical attention. I would suggest u to
immediately call 911 and bring him to the medical center. Meanwhile I will suggest u that
please do not put fingers in his mouth or perform any blind finger sweep bc the foreign body
ma become more deeply lodged, if it is actually present. In case if u observe a significant
respiratory compromise or chocking, please perform a Heimilich’s maneuver by thrusting
tummy with sudden pressure..
Hope u understand whatever we discussed today. Do u have any concern/questions? Alright

then, I will see u once u get to the hospital. Take care. I am sorry Mrs. Jones I was encountered
with some unexpected delay with previous patient. Now that I am here I assure u that I shall
give u my undivided attention.
Investigations:
Physical exam, ABGs, CBC, x-ray chest, Direct laryngoscopy/Bronchoscopy.
40. Bed wetting
DDs: Primary: Normal <5 years, Family history
Secondary: UTI, Obs: sleep apnea, DM, Functional bladder disorder, Constipation, Cystitis
DOPEFAA
Associated:
Is he ever toilet trained?
Do u reward him for dry nights?
How has the behavior affected the child/ you?
Does he drink water before bed time?
Did u try any medication/intervention?
How are his bowel movements?
Any fever/belly pain? (UTI, Cystits)?
Does he snore while sleeping?
Is there any stress in his life?
Did u change ur place recently?
BC-FUN-SHIP, ABCOP, FNVTTT, PAMHUGSFOS.

41. Jaw pain (Domestic violence)
Introduction:
Jaw pain: DOPEFAA and LIQR

I’ve noticed bruises and bandages on your arm and wrist, what happened to you?
You look anxious and concern, in there anything that is bothering you? Would you like to share
with me please?
I don’t know if this is the problem for you but many of pts are in a abusive relationship. So I
have started to ask about it routinely. Are you in a relationship where you are physically and
emotionally abused?
I assure you whatever you will tell me it will remain confidential bw us and nothing will be
released to anyone wilthout your permission.
Miss…. You can trust me. I might be right person for you with whom you can share your
problem. I will do everything possible to make sure that you are safe and sound.
SAFE-GARD
S: Are you safe at home?
A: Are you abused by anyone?
F: Have you discussed this problem to anyone in your family?
E: Do you have an emergency plan?
G: Do you have any weapon/Gun at ur home?
A: Does your boyfriend/husband drink alcohol?
R: How is your relation with your boyfriend/husband?
D: Any depression symp(MICE)

Let me explain u emergency plan: try to keep a bag I which you keep your valuable things and
money and give it to ur dear ones, whenever you feel threat you leave the home.
Do you have kids?
How many kids do you have?
How is their relation with father?
If you suspect that your child is being abused, I will inform child protective service.
Since how long he is hitting you?
How frequently he is hitting you?
Through which thing/object he is hitting you?
Physical Examintion:
Closure:
Thank you for you kind co-operation and patience, I am done with my examination. Now I
would like to give you my impression regarding your problem. Is that ok?
Well miss I am really concerned about your relation with your husband/boyfriend, I would like
to inform you that violence is against the law and you don’t deserve to be abused. Violence
never ends on it own, it almost always increases in severity overtime. The only way to stop
abuse is to get away from abuse. Do you have any safe place to stay?
Miss plz don’t worry fortunately we have good social workers who will arrange safe place for
you.
42. Post cholecystectomy (5 days constipation)

Phone case:
Introduction:
DOPEFAA
When were you Hospitalized?
What was the reason of hospitalization?
What surgery was done?
Any complication during/after surgery?
When did you pass urine after surgery?
When did you pass stool after surgery?
What was color of your stool? Consistency? Any blood in stool? Belly pain?
When did you pass ur last stool?
Are you passing gas?
Do you feel nauseated/vomiting?
Do you have any pain/discharge at the site of incision?
When were you mobilized after surgery?
How long did you stay in hospital?
Tell me about ur diet?
Any medications for constipation?
Closure:
43. Polyuria + not gaining weight
DDs: DM1, DI, Parasitic infection
Phone case:
Introduction:
discuss..
DOPEFAA
What was his weight last year?
What is his weight now?
How is his appetite?
How many times do you offer him meal?
Please tell me more about his diet?
Have you noticed any changes in his urinary habits?

How is his school performance?
urinary BCFUNSHIP, FNV, PAMHUGSF, BINDERS
Closure:
44. Fever with seizures

Phone case:
Introduction:
discuss..
Fever:
DOPEFAA
Did you check the temperature?
How high it was?
Does he has chills?
Any recent illness?
Does he has any rash?
Did he take any medications for fever?
Any ear tugging?
Seizure:
How long did it last?
Was the jerky movement generalized or it involve any specific part of body?
Did she bite her tongue?
Did you notice any frothing from his mouth?
Did he loose control of his bladder?
Was she confused/sleepy after regaining consciousness?
FNV, PAMHUGSF, BINDERS
Closure:
45. Baby with belly pain (Psychiatric case)
Phone case:
Introduction:
discuss..
DOPEFAA and LIQR

How is his behavior at home?
How is his behavior with peers?
Is there any new changes in his home environment?
Are you giving proper time to baby?
Is there any new changes in his school environment?
How is his performance in school?
How are his symptoms at weekends/holiday?

FNV, PAMHUGSF, BINDERS
Closure:
46. GERD Refill

Hello Mr Jones, I am Dr David attending physician in this hospital, I am glad that you are here. I
appreciate that you are taking good care of your health.
How can I help you?
I will surely help you before I refill your medication I would like to ask you some questions
regarding your health and will do brief physical examination. Is that ok?
When were you first diagnosed?
Were any investigation done at that time?
What were symptoms at that time?
May I know what medications you are taking?
Are you compliant with your medications?
Are you taking medications regularly?
When was your last check up done?
How are you symptoms now?
Do you have cough?
Do you have SOB?
Do you have chest pain?
Do you have heartburn/waterbrash?

Are you anxious about any thing?
If history of esophagitis then since how long do you have? Are you taking any medications for
that?
FNVTTTTT
PAMHUGSFOS
Closure
All the best for CS exam……

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Written by: SUB-34

For all my sweet friends…..

Are you feeling comfortable in this room?

If the patient is draped then,

Is there anything else I can do to make you more comfortable?

If the patient is not draped then,

So Mr. Jones, How can I help you today? Or

What brought u to the hospital today? Or

What made you come here today?

D: When did it start? Duration

O: How did it start? Onset

P: How is it progressing? Progression

E: What do you think that might be causing your problem?

A: What makes it better? Alleviate

A: What makes it worse? Aggravate

L: Can you locate your pain? Location

Q: Can you describe your pain for me? Quality

R: Does your pain move anywhere else? Radiation

V: Did you throw up? (Vomiting)

T: Do u have problem in adjusting Temperature of ur surrounding?

T: Did you Travel anywhere outside USA in recent past?

T: Do you have any physical injury anywhere? (Trauma)

T: Do you have any peT at your home?

M: Are you taking any medication?

H: Were you hospitalized for any medical or surgical reason before?

U: How are your urinary habits?

G: How are your bowel habits?

S: How is your sleep?

Are there any similar complaints in the family?

O: Obs and gyni history

1. When was your last menstrual period?

C: Have u ever felt a need to cut down ur drinking?

A: Have u ever felt annoyed by criticism of your drinking?

G: Have u ever felt guilty about drinking?

Counsel to stop drinking alcohol

I am sorry to ask this, Don’t mind me asking that Mr. Jones

1. Do u use any illicit drugs?

Counsel to stop taking drug illicit

S: Are you sexually active?

Sorry to ask this, do u have any other partner? If Yes,

Do u use any form of protection like condom?

Chest pain, 4-5 episodes of sweating, pain radiating

Are you feeling comfortable in this room?

Is there anything else I can do to make you more comfortable?

So Mr. Jones, How can I help you today? Or

What brought u to the hospital today? Or

What made you come here today?

CHIEF COMPLAIN: Chest pain

Pulmonary embolism / Pul: infarction / Pleuritis (Resp)

Chostochondritis / Rib #/ Muscle strain. (Musculoskeletal)

D: When did it start?

E: What do you think that might be causing your problem?

A: What makes it better?

A: What makes it worse?

Q: Can you describe your pain for me? Quality

Do u have SOB while lying down?

Do you wake up in the middle of the night gasping for breath?

How many pillows do u use while sleeping?

Do u have any wheeze?/cough?/runny nose?

Do u have excessive sweating?

Do u have swelling of ur ankle/feet?

Do u have rash? (Pericarditis caused by coxsackie virus)

Do u have joint pain?