General

History:
Knock confidently!!
- Good Morning, Mr./Ms. xxx, I am Dr. Richard, your doctor for today. How may I address you?
- Are you comfortable with the room temperature? Please let me cover you.
- May I sit down before we start? Thank you! So, How may I help you today (on your CC)?

(if acute distress: I can see you are suffering from CC right now. I am going to try my best to help you
as fast as I can. Let's start with some questions regarding this pain)

"Angry Pt": I see you are angry about my late, I apologize for kept you waiting. I am here for you now
and you have my full attention.
I understand your point of being unprofessional on patient appointment management; we
will try to provide a better service in your next visit. However, I want to stress that certain issue
doesn't affect my professionalism as being a primary care physician for you.
If after our meeting today you still prefer a different doctor, I will be more than happy to
arrange that for you.

SIQRAA
- Plz tell me more about this CC?//Plz point to where the pain hurts.
S - When did it start?/When did you start feeling this way?(Psych case)/Did it come on suddenly or
gradually?
I - If 10 is the worst pain you've ever had, how would you rate this pain from 1 to 10?
Q - Is the pain/feeling constant or does it come & go?
-> How often do you get this pain?/How many times did you vomit today?/How many pads or
tampons did you use today?
-> How long does each episode last?
- How would you describe this pain? (ACS: tight, pressure, squeezing/Dissection: ripping,
tearing/Fracture: sharp/Pneumothorax: Pleurisy/Misc.: Dull, Burning)
R - Does the pain move anywhere? (Angina to arm, neck, back, jaw/Gallbladder to right
scapula/Sciatica down to leg, calf/Peritonitis or perforation to Shoulder/Pharyngitis to ear/Kidney
stone to Groin)
"What do you think it's the cause of the pain?/Did anything unusual happen at that
time/before the pain?"
AA - Does anything make it worse? Does anything make it better?/Have you tried anything to make
yourself feel better
A - Do you have any other symptom that comes w/ the pain/symptom? (MI: Diaphoresis, confused,
lightheaded)
- How's your diet? Any change in Appetite? Any change in your weight?
- Do you exercise regularly? Any weakness feeling lately?
- Any change in urine habit? Any change in bowel habit?
- Any headache? Any change in vision?
- Any shortness of breath? Any chest pain? Any heart racing?
- Any abdominal pain? Any joint pain?
- How's your sleep? How's your mood?


How was this affecting your life?
What concerns you the most about this CC?
Is anyone taking care you when you need help/are sick?

PAM H FOSS
I am going to ask you a few questions about your health in general:
P - Have you ever had previous episode like this/of CC before? How often does it occur? How long
does each Episode last?

A - Are you allergic to anything? any medication?

M - Do you use any prescribed or over-the-counter medication?

H - Have you ever been diagnosed with other major illness? How do you manage it? (Are you taking
the medicine on regular basis? When was your last dose?)
-> Have you ever been hospitalized? Any surgery? Any trauma?

I am going to ask you a few questions regarding your family health history:
F - Anyone in your family had similar symptoms? Any other major illness? (DM, HTN, stroke)

I am going to ask you a few questions about your women's health:
O - Have you ever been pregnant? How many times? How many children do you have? Any
miscarriage or abortion? Any complication during pregnancy or delivery?
When was your last period? Is your period regular? How many pads or tampons do you use on your
first day? How many days do you bleed?
When did you have your first period?
When did you last have your period (if menopause)?

When was your last pap smear? Was it normal?
When was your last mammography (F>50)? Was it normal?

Now I am going to ask a few personal questions, at this point, I will remind you that everything we've
discussed here are kept confidential.
"I understand your concern that this might be irrelevant to your pain/symptoms, but your answers
will help me to rule out other diagnoses/causes of your CC."
Sex - Are you currently sexual active? (Do you have problem w/ erection?) How many partners do you
have in last 6 months? Do you use condom during intercourse?
Have you ever been tested for sexual transmitted disease? what about HIV test?
Social - Do you drink alcohol? How often do you drink? How much do you drink per day/week?
CAGE: Have you ever thought of Cutting down your drinking? Has Anyone criticize you about
drinking? Do you feel Guilty about drinking? Do you need a drink when you first wake up in the
morning?

Have you ever used any tobacco-related product? (Before you quit,)How many packs do you smoke
per day/year?

Have you ever used any recreational drugs? What do you use? How often do you use it?
Common names for drugs
Alcohol: booze, brews, brewskis
Amphetamines: speed, crank, crystal, meth
Cannabis: hash, hashish, dope, pot, reefer, bud, ganja, weed, grass
BZD/Barbiturates: downers
Heroin: Horse, brown sugar, smack
Phencyclidine: PCP, angel dust
Anabolic steroids: Roids

What do you do for a living? Are you exposed to any risk in your job?
Do you live w/ anyone? How's life at home?/Do you feel safe at home?/Any violence?


Ped:
REVIEW OF SYSTEMS PEDIATRICS - FEVEER CUDDS
Fever: Does your child have fever?, How high is the fever?, Does he/she have chills?,
Does he/she have night sweats?

Ear pulling: Does he/she pull his/her ear frequently?

Feeding: "When was the last time you feed her" "Any problem swallowing?"
Vomit: Has ______ throw up?, What color was the vomit?, Did you see any blood in it?,
Any food in the vomit?, Does he/she have nausea?
Eye discharge: Does he/she have any eye discharge?, How is it?
Ear discharge: Does _______ have any ear discharge?, How is it?
Rash: Does he/she have any skin rash?, Where is it?, When did it start?, Where did it first
appear?, Is it moving to somewhere else?, Is it itchy/painful?
Chest symptoms: Does he/she have cough/runny nose/chest pain/SOB/difficulty
swallowing/difficulty breathing?, How often does he/she cough?, Any sputum?, How is
the sputum?/Any blood in sputum?
Urinary: Has _______ increase or decrease the amount of urine?, How many diapers does
he/she use?, Any change in the color/odor of the urine?, Does _____ have pain when he/she
urinates?
Diarrhea: Does ______ has diarrhea?, How many times did he/she had diarrhea?, Any blood
in stool?, Does he/she have pain or cries during defecation?, Any change in his/her bowel
habits?
Dehydration: Does ______ have dry mouth?, "Any Change in numbers of wet diapers used?"
Are his/her diapers wet?, How long since his/her last wet diaper?, When ____ cries can you
see any tears?, How is his/her energy?
Seizures: Does he have any jerk movements?, Has he/she been shaking?, Is any leakage of
urine/stools during/after the shaking?, How is his/her level of consciousness?, How is _____
after the seizure?

Prenatal:
How was the mother's health during pregnancy? Any complication during pregnancy?
Any infection, illness, or vaginal bleeding?
Did the mother take medications? any smoking? any alcohol drinking? any recreation drug
usage?
Did the mother attend routine checkup?

Birth:
Was the pregnancy full term?
How much did the baby weigh?
What was the type of delivery? Any complication?

Neonatal:
How was baby after delivery? Did the baby turn blue or yellow? any breathing problem/need oxygen
after birth? any shaking?
How long did mother and child stay in hospital after delivery?

Feeding:
Was the child breast or bottle-fed? any problem during feedings?
When was solid foods introduced?
How's the child's appetite?
Does he/she take daily multi-vitamin? any food allergy?

Developmental/Routine Care:
When was the last time he/she has routine checkup? Did doctor say anything?
When did he/she first smile (2mo)/sit up (6-7mo)?
When did he/she start crawling (9mo)/talking (10-12mo)/walking (1yo)/to dress him/her self/start
using short sentences?
Is he/she up-to-date with vaccinations?


SSC-WTD
Smile
Sit
Crawl
Walk
Talk
Dress
Month
1
6
9
12 (1 yo)
15 (1.5 yo) 30 (2.5 yo)


Adolescent Case:
CONSENT FIRST: 3 places:
Door (Did the parent referred daughter/son to see you?);
Phone (I have your daughter/son with me and I want to verify that I have permission to take care of
her/him today);
Ask (Do your parents know that you come to see me today?)
HPI:
How is your child's body image? any change in weight?
Do they often go to the bathroom during dinner? Do they have watery eyes after they return?
Do they exercise? How often?
Any change in your child's school performance?
Sex + Social
dx: Non-specific chest pain - Costochondritis;
Athletic passing out in sport - Cardiomyopathy (ask FMH);
AB pain and fever - ask Sore Throat;
Epistaxis - ask Drug hx


HISTORY OF PRESENT ILLNESS: FATIGUE
Progression: "How does this fatigue affect you throughout the day?","Do you feel increasingly
tired throughout the day?"
Infections: Have you ever had any infections lately?, Any illness?
Post Traumatic Stress Disorder: Any traumatic event in your life lately?
Anemia: Have you been diagnosed of anemia in the last year?, Do you have any
palpitations?
Depression: Are you feeling sad/down/low energy?, Any change in weight?, How is your
appetite?.
Thyroid: Do you feel cold when others do not?, How's your appetite?, Any change in your
weight?
Obstructive sleep apnea: Do you snore at night? "Do you feel sleepy during the day?"


HISTORY OF PRESENT ILLNESS: SPOUSE ABUSE - SAFE GARDDS
3 Points:
Safety (I want to remind you that you are absolutely safe in this clinic; Do you have anywhere else to
go when your home is not safe?);
Confidentiality (Everything we discuss here will be kept strictly confidential);
Law (Although you might not want to talk about this right now, I want you to know that IF there is
any chance that you are being abused, the Law is always on your side to protect you, and we can
provide a shelter.)

Taking Photos: For your protection, I need to take pictures of these wounds for record. They will be
kept confidential in your file only.

Safe: Do you feel safe at home?
Alcohol: Does your husband use alcohol?
Family/friends: Does your family member or friends know about this situation?

Emergency: Do you have an emergency plan?

Guns: Is there any firearm in your house?
Abuse: Are your kids abused too?, Have you been abused?, How did it happen?
Relationship: How is your relationship with your husband/boyfriend?, Do you feel
threatened by him?.
Depression: Are you feeling sad/down/low energy?, Any change in your weight?, how is
your appetite?.
Drugs: Do you use any recreational drug?, Does your husband/boyfriend use any
recreational drug?, How often does he use it?,
Suicide: Have you ever thought about killing yourself?, Could you please tell me more about
your plan?

HISTORY OF PRESENT ILLNESS: FORGETFULNESS/MEMORY LOSS/DEMENTIA/ALZHEIMER
- FORGETTS HIM DEATH SHAFTS and Loss The Medicines

Fall: Have you had any recent loss of conscious?
Orthostatic hypotension: Do you feel dizzy when getting up from bed or chair?
Running Urine incontinence: Have you ever lost control of your bladder?, Have you ever
fail to make it to the toilet on time?
Gait: Do you have any problem walking?
Eye: Any vision problems?
Trauma: Any recent trauma/injury?
Tingling: Any weakness/numbness in your legs/arms?
Speech difficulties: "Any problem with your speech?

Headache: Any headache lately?
Infections: "Any infection lately?
Mood: Do you feel sad?, How is your mood?

Dressing: Do you have any problem getting dressed?
Eating: How is your appetite?, Do you need help feeding yourself?
Ambulation: When you go out, can you find your way back home?
Toilet: Do you go to the toilet by yourself?, Do you need any assistance in the toilet?
Hygiene: Do you need any assistance bathing yourself?

Shopping: Do you shop by yourself?, When was the last time you went to the grocery store?
Housekeeping: Do you need help cleaning your house?
Accounting: Do you pay your bills by yourself?,
Food: Do you cook yourself?, Do you need assistance cooking?
Transportation: Do you drive?, Do you know which bus takes you from home to here?
Support: Do you feel supported by your family?

Laundry: Do you need help doing your laundry?
Telephone: Do you need help using the phone?, Plz tell me the number of your
daughter/son?
Medication: Do you need help taking your medications?, Do you know the names of your
medications?


HISTORY OF PRESENT ILLNESS: FOLLOW UP VISIT - TOLS CARM

Treatment: What medications do you take?, How often do you take it?, "Is the dosage
taken as prescribed?"
Onset: When were you diagnosed of______?
Last checkup: When was your last checkup?
Side effects: Have you experienced any side effect from the drug

Compliance: How do you take your medication?, When did you start your last bottle of the
medication?, How many pills do you have left?
Actual status: How do you feel now?
Related symptoms to the disease: Do you have any other symptom?
Monitoring: How often do you check your blood pressure/blood sugar?, When was the last
time you check? "Was it normal?"


HISTORY OF PRESENT ILLNESS: HEADACHE


LIQQORAAAA PPD





ATNT WIRELESSSS

Aura: Tell me what happened before your headache?, Any change in your vision before the
headache?, Did you hear any sound in your ears before the headache?, Any numbness or
tingling before the headache?, Any vision problems during/after the headache?, Are you
afraid of light?
Timing: When does the headache start?, How often do you get the headache?, How long
does each episode last?, Do you have the headache at certain time of the day?, Does the
headache wake you up at night?
Nausea/vomit: Did you feel nauseated before/during/after the headache?, Did you vomit?
Tearing/Runny nose: "Any tears during headache?", "Any discharge from your nose?"

Weakness: Did you feel numbness/weakness during/after the headache?
Injury: Did you have any head trauma before the headache?
Estrogen exposure: Have you been taking any estrogen pills, like birth control pills?
Limb/joint pain: Any pain in your joints?
Energy: How is your energy?
Stress: Do you feel more stressed lately?
Speech: Any trouble with your speech?
Stiff neck: Do you have stiff neck?
Sinusitis: Any pain in your face?, "Any cough?, "Any fever?


HISTORY OF PRESENT ILLNESS: THYROID - ABCD HSV

Appetite: How's your appetite?, Any change in your weight?, How many pounds did you
gain/lose?, Over what period of time did it happen?
Bowel habits: "Any change in your bowel habits?, Are you constipated?, Do you have

diarrhea?, How long have you been constipated/with diarrhea?

Cold intolerance: Do you feel cold/hot when others do not?
Depression: Do you feel sad/low on energy to do the things you used to do?

Hair: Any change in your hair?

Skin: Any change in your skin?, Is your skin dry?
Voice: Any change in your voice?,

HISTORY OF PRESENT ILLNESS: JOINT PAIN - CITRUSS HP TUDE

Chest pain: Have you had chest pain?, Any cough?, "Any difficulty breathing?
Insect: Any insect bite lately?/Have you travelled to mountains/woods lately?
Trauma: Any injury/trauma in your ______?, Have you been doing excessive exercise?
Rash: Any rash lately?, Where is it?, When did it start?, Where did it first appear?, "Is it
moved to somewhere else? "Is it itchy/painful?"
Ulcers: Any ulcer in any joint?, Any ulcer elsewhere?
Stiffness: Is your _____ stiff?, When did it start?, Does it get better with movement?
Swelling: Is your _____ swelling?, Is your _____ red/warm?

Hair: Any hair loss?
Photosensitivity: Do you get any rash when are exposed to sun light?, Where do you get it?

Temperature: Any fever?
Urinary: Any burning during urination?, Any vaginal/urethral (from penis) discharge?
Digestive: Any change in your bowel movements?, Do you have diarrhea/constipation?,
How long have it been?, Have you ever been diagnosed of bowel disease before?
Eye: Any pain in the eye?, "Any eye discharge?


HISTORY OF PRESENT ILLNESS: LOSS OF CONSCIOUSNESS


Before Loss of Consciousness: PAN DVD HDC
Palpitations: Did you feel heart racing/beating faster?
Aura: Did you have any symptoms before fainting?
Nausea/vomit: Did you feel nauseated before fainting?, Any vomit?

Difficult breathing: Any difficulty breathing before losing consciousness?
Vision: Any vision problem before?
Dizziness: Did you feel dizzy or lightheaded before fainting?

Headache: Did you have headache before fainting?
Drugs: Did you take any drug before this episode?, Do you use any recreational drug?
Chest pain: Did you have chest pain before fainting?



During Loss of Consciousness: TISA
Tongue: Did you bite your tongue during the event?
Incontinence: Any leakage of urine/stools during the event?

Shaking: Any jerky movements or shaking?, Did something come out of your mouth?
Attending: Was someone with you during the event?

After Loss of Consciousness: We Go Home Confused and Concentrated

Weakness: Did you feel weak?,
Gait: Did you have any problem walking?
Headache: Did you have headache when you woke up?
Confusion: Do you feel confused?
Concentration: Can you concentrate as you use to do before the event?

HISTORY OF PRESENT ILLNESS: PSYCHIATRIC

Sleep: Any problem falling sleep/staying asleep/waking up?
Interest: What are your hobbies?, Do you still find them interesting?"
Guilty: Do you feel guilty about anything?
Energy: How's your energy level lately?
Concentration: Can you focus on things as you used to be?
Appetite: "How's your appetite?, Any change in your weight lately?, How many pounds did
you gain/lose?, Over what period of time did it happen?, Was this gain/loss of weight
intentional?
Anxiety: Are you more worrying about things than usual?, What are you worrying about?,
Does it affect your sleep?, Does it affect your concentration?
Psychomotor: Do you feel restless or slowed down?
Suicide: Have you thought about killing yourself or hurting others?, Do you have a plan?,
Please tell me more about your plan.
Memory: Do you have any memory problem?, Please repeat these 3 words after me: Apple,
Boy, Cat?, (after MMSE) "What was the 3 words I asked you a while ago?"
Hope: Do you feel hopeless?
Hallucinations
->
Visual(Grief,
DT/Drug,
eg,
Levodopa/Carbidopa
Entacapone)/Auditory(Schizophrenia)/Olfactory(Seizure): Sometimes when PEOPLE are
under a lot STRESS, they see or hear things that other do not. Does this ever happen to you? ----
>What do you see/hear? Can you see them or hear them w/ your eyes close? -------> Is
the image/voice telling you anything? -------> Does it tell you hurt yourself or hurting
others? ------------> Do you feel that you've been controlled?
Delusion -> Schizophrenia/Psychosis/Mania/DT: "Do PEOPLE ever say they think you have
extremely unrealistic ideas about yourself or your life?
Odd/Paranoia: Do you think PEOPLE are out to get you? Following you? Do you think you
are on a government list?
Sad: Do you feel sad?, How long have you been feeling sad?
Social: How is your social life?"
Job: Do you have any problem in your job?, How is your performance in your job?
Family/friends: Do you have any friend/family member you can talk to?, How do they react
when you tell them how you feel?, Do you feel supported by them?
Traumatic event: Any traumatic event/significant life change lately?
Thyroid: " Do you feel cold when others do not?" "Any hair loss?", "Any skin change? "Any
change in your weight?", "Any change bowel habit?"
Anemia: "Any SOB?", "Any racing heart?"
Differential Dx:
- Occurs in winter: seasonal

- Low level lasting > 2yrs: Dysthymic

- Soldier returned home from War: PTSD
- Wife died 3 wks ago: Normal Grief; if >3 yrs: MDD
- Episodes of rapid speech, boundless energy, gambling/shopping: Bipolar
- Gave birth last month: Post-partum Depression

Depression:
S - I see you are here because of ___________, can you tell me more about it?
I - How is this affecting your life?
Q - How does this make you feel?
O - When did it start? What was going on in your life when it started?
AA - what makes it better? What makes it worse?
SIGECAPS
- Do you have problem Sleeping?
- Have you lost any Interest in anything you've enjoyed?
- Do you feel Guilty?
- How's your Energy? is this fatigue constant? How does this fatigue affect your life? (Dysthymic = NO)
- How's your concentration?
- How's your appetite?
- Do you feel slower than before? Has anyone told you about it?
- Have you ever thought about hurting yourself or others? Do you have a plan?
=>Hypothyroidism:
- Do you feel cold when others do not?
- Any hair loss? any skin change?
- Any change in your weight? How about bowel habit?
=>Anemia:
- any SOB? any racing heart?

How was this affecting your life? What concerns you the most about this CC? What do you think
it's the cause of your problem? Is anyone taking care you when you need help/are sick?

Schizophrenia:
1. Hallucination - sometimes when PEOPLE are under a lot STRESS, they see or hear things that other
do not. Does this ever happen to you?
2. Delusions - Do PEOPLE every say they think you have extremely unrealistic ideas about yourself or
about your life?
3. Paranoia - do you think PEOPLE are out to get you? Following you? Do you think you are on a
government list?

How was this affecting your life? What concerns you the most about this CC? What do you think
it's the cause of your problem? Is anyone taking care you when you need help/are sick?

Counseling - Would you like to talk things over with a counselor? A good counselor can help you
through this difficult time.
How about joining a support group? You are not alone, and there are people ready to
help any time.


General Anxiety Disorder:
- Excessive, unrealistic worry and tension (FOOT tapping), even if there is little or nothing to provoke.
- Restlessness/Feeling keyed up/on edge
- Easily fatigued
- Difficulty concentrated
- Irritability

- Sleep Disturbance
- A&O x3, normal/depressed mood; Affect preserved.
PE: Sweaty palms, tremor, rapid HR, SOB, stomach cramping, feeling of lump in throat, frequent need
to urinate, dry mouth, nausea, diarrhea, headaches/neckache/backache.

Social Anxiety Disorder:
- Social Phobia: overwhelming worry and self-consciousness about everyday social situation.
=> Ask about any difficulty in: speaking in public, eating in a restaurant, using public washroom.
- NO Supporting Group!
- fear of being judged by others/



HISTORY OF PRESENT ILLNESS: DIZZINES
What: Tell me more about your dizziness.
Onset: When did it start?
Constant: Is this all the time or come and go?
Progression: Is it getting worse or better since it's started?

Duration: How long does each episode last?
Timing: When do you feel dizzy in a day?, Is at the same time everyday?
Position: Does any position make you feel dizzy?

Black out: Did you black out?
Tinnitus: Any ringing in your ears?
Consciousness: Did you lose consciousness?
Hearing: Any change in your hearing?

Nausea/vomit: Did you feel nauseated?, Did you vomit?


HISTORY OF PRESENT ILLNESS: VAGINAL DISCHARGE
Amount: How much is the discharge? 1 teaspoon, 1 tablespoon, 1 cup?
Burning: Any burning sensations in your vagina?
Pain/pruritus: Any vaginal pain/itching?"
Color: What is the color of the discharge?
Consistency: What does the discharge look like?
Duration: When did the discharge start?, How long have you had the discharge?

Last menstrual period: When was your last menstrual period?
Odor: What does the discharge smell like?
Oral contraceptive: Do you use birth control pills?, How long have you been taking the
pills?
Sexual activity: Are you sexual active?, How many partners do you have in the last 6
months? And in the last 10 years?, Do you use condom during intercourse?, Have you ever
had any sexually transmitted disease? What about HIV test?

HISTORY OF PRESENT ILLNESS: DIABETES - DDIABEETICS
Duration: When were you diagnosed of diabetes?
Date of last checkup: When was your last checkup?
Insulin/medications: What medications do you take?, Do you use insulin?, What insulin
do you use?, How often do you inject your insulin?, Where do you inject?, Are you taking
medications as prescribed?

A1c Hemoglobin: Do you monitor your blood sugar?, How often?, When was the last time
you check?, How was it?
Blurry vision: Any change in your vision lately?
Extremities: Any injury in your limbs?, When did it happen?, How is now?
Erections: How is your performance during sex?
Tingling: Any numbness/weakness/tingling in your legs?
Infections: Any infection lately?
Cardiovascular risk factors
Side effects: Have you noticed any side effects of the medication?
MEDEM
1) I want you to monitor your blood pressure 3 times a week, blood sugar 2 times per day,
once before breakfast & once after dinner.
2) Plz keep your feet dry and clean. No smoking, No drinking.
3) Plz keep a low salt, high fiber, low calorie diet
4) Plz start exercising slowly
5) Please be cautious when changing your current drugs.

HISTORY OF PRESENT ILLNESS: HEMATURIA - HITTERS
Hematologic: Do you have any bleeding or bruise on your body?, Have you ever been
diagnose of any bleeding problem/blood disease?
Infections: Any burning sensation during urination?, Any pain in your back?
Trauma: "Any trauma or injury in your lower abdomen?
Tumor: Have you been diagnosed of cancer?
Renal disease: Do you have any renal disease?
Stones: Any renal stone?, When did it happen?, What was the treatment?

DELIVERY BAD NEWS - SPIKES
Setup:
Enter the room, look the patient in the eye and do your standard introduction
I have scheduled a full 15 minutes and asked my nurse not interrupt us
I have turned off my pager and asked that we not be disturbed

Patient perception
Ask the patient what he thinks about his health problem, what he understands so far about
the workup of his condition.
Do you remember why we did this test?
What did you think the (symptom) was from?
Did you think it was something more serious?
Have you seen any other physician for this problem?
What did the doctor tell you?
Do you remember the doctor talking to you immediately after the test?
The doctor (explain what he did)

Invitation
I have the results back. Would you like to go over them now?
Would you like the basic information or all the details?
So if turns out to be something serious you would like to know?

Knowledge

 Mr./Ms.______, I am sorry to have to tell you that the pathology report shows that what you
have is serious and will require treatment.
The biopsy showed a tumor.
When we looked at the biopsy with a microscope, we saw that the tumor is cancerous.
The test shows that you have: ___________
I know this must be difficult. I will be there to help you through all the process.
I know this is serious news. But first we have to do some additional test to find out the
extent of the cancer. It is important to remember that, no matter what, there are treatment
options available for your condition.
The type of cancer you have does have treatment options, and I will be with you every step
of the way. But first let's get the additional test to see exactly what we are dealing with.

Emotions: this is a good time to use the appropriate touch in the shoulder or forearm and offer
the patient a tissue or sip of water, or just sit quietly for a few seconds.
I can see you are upset. I was also upset when I got the results. Who do you have at home
to help you dealing with this? With your permission, I would like to talk to your family or
anyone else who will be helping you.
What you have is serious, but we first have to do some additional test to find out exactly
how advance it is. Either way, we do have treatment options and we are going to be very
aggressive. I will help you through this entire process. At our hospital, we also have
counselors and support group of other people going through the same thing.

Summarize
Mr./Ms. ________ I know I gave you a lot of information to remember today. I want to make
sure you understand me correctly.
Do you have any questions? If you get any questions or concerns, please feel free to
contact me at any time.
My nurse is going to give you my contact information, please feel free to call me if you have
any questions before your next visit. I will get all the test scheduled today with my nurse. I
would like to see you next week, and we will go over all of the results. Is that right with
you?

Physical exam (2-3minutes)

"Mr./Ms. xxx, before I start PE, is there anything you want add regarding your CC?"
Okay, Ms. /Mr. ..., I am going to exam your...... (Transition)
Im going to ...
Inspection: take a look at your ....
Palpation: press on your ....
Percussion: tap on your ....
Auscultation: listen to your ....
Do the maneuver

HEENT:

I am going to take a look on your head.

I am going to press on different parts of your
head and face. Any pain?
I am going to take a look at your eyes. Please take
off your glasses. Plz look up, plz look down. You
can put the glasses back on.
I am going to check your visual fields. How many
fingers am I holding?

Inspection from left and right

Palpation of the Head (Occipital, Temporal,
Frontal), Sinuses (Frontal, Maxillary, Ethmoidal
w/ thumb
Inspection of Conjunctiva & Sclera
Visual Acuity

Now plz cover one eye. Tell me when you see my

fingers
Plz cover the other eye. Tell me when you see my
fingers
Plz follow my fingers w/o moving your head
I am going to shine a light in to your eyes. Plz
relax and look straight ahead.
Now I am going to check the back of your eyes
I am going to take a look at your Ears
I am going to press on your ears. Any pain? Any
pain?
Plz close your eyes. Can you hear this? Can you
hear this?
I am going to put the tuning fork on top of your
head. Is the sound equal on both sides

I am going to look inside your ears

I am going to look inside your nose. Plz tilt your
head backward.
Plz open your mouth.
Plz stick your tongue out. Plz say AH.
Plz move your tongue side to side. Thank you.

Neck/Thyroid:
I am going to take a look on your neck
I am going to listen to your neck, plz hold your
breath when you feel my instrument.
M >45yo, F >55yo
I am going to press around your neck. Any pain
I am going to press on glands in your neck. Do you
need a cup of water to help swallowing? (Get
water while washing hands)
Plz sip water and hold it => now swallow.
I am going to check on your forearm skin.
Any dry skin lately? Any hair loss?
Plz stretch out your arms out and spread fingers.
Plz close your eyes.
You may open your eyes now.
I am going to press on your legs. Plz pull up the
cover.
I am going to check your reflex of your legs. Plz let
me grab my instrument.
I am going to feel the pulses of your arms and
legs.
You may lower the cover now.

VF x 4q + Central Scotoma
VF x 4q + Central Scotoma
EOMI CN 3,4,6
Check fundoscopy in front of Pt. Light do NOT
cross nose-bridge!
PERRLA.
Ophthalmoscope - HTN, DM, Headache.
Ear Inspection
Palpation: Pre-auricular, Mastoid Bone.
Rub fingers at ears -> Gross hearing.
Now I am going to put the tuning fork back here.
Can you hear it?
Let me know when you cannot hear it any more.
Can you hear it in your ear?

Otoscope w/ cap ON. Pull on Pinna; do Not let go

if painful.
cap OFF!
put Otoscope back.

Inspection
Carotid auscultation, 3 seconds each side.
Lymph nodes: from back to submandibular
Palpation of Thyroid

Inspection of forearm skin/hair

Tremors
Thumb on tibia for Myxedema
DTR on knee & Achilles.
Peripheral pulses: DP, PT, and Radial

Plz lower your gown. Let me help you untie.

I am going to listen to your heart. Plz breath
normally
You may pull up the gown now. Let me help you
re-tie

Chest/Lung: Check ENT first if Pt is w/ URI
Plz show me your hands. Plz make a shape like
this.
Now I will give you instruction from your back.
Plz expose your back. Let me help you untie. Plz
hold your hands to shoulders.
Plz take a deep breath.
I am going to tap on your back. Plz breathe
normally.
I am going to press on your back. When I press,
plz say 99.
Now I will press on your spine. Any pain?
I am going to listen to your lungs. Plz breathe
deeply when you feel my instrument. (after 2 lvl)
are you ok?
(Walk back to front)
You may lower your hands now.
Plz lower your gown. Plz take a deep breath.
I am going to tap on your chest. Plz breathe
normally.
I am going to press on your chest. When I press,
plz say 99. Any pain?
I am going to listen to your lungs. Plz breathe
deeply when you feel my instrument.
I am going to listen to your heart. Plz breathe
normally.
You may pull up the gown now. Let me help you
re-tie

Heart:
Plz show me your hands. Plz make a shape like
this.
I am going to look at your neck.
I am going to listen to your neck. Plz hold your
breath when you feel my instrument.
(Adjust to 45). Plz lower your gown before lying
down. Let me help you untie.
I am checking on your neck now. Plz turn your
head away from me. Now plz turn to me.
I am going to press on your chest. Any pain?
I am going to listen to your heart.
I am going to feel your heart. Plz hold your breast
up for me? Thank you
Plz sit up now. I am going to listen to your heart
again.
You can raise your gown now.
I will listen to your lung in your back now. Plz

APTM

Cyanosis/Clubbing
Inspection of back

Percussion 3 lv + mid-axillary line x bilateral.

TVF + Paraspinal + Spinal tenderness.
Full cycle bilaterally x 3 lv + mid-axillary line.
*SP may hold breath at one side to mimic
decrease breathing sound!
Inspection of chest
Percussion 2 lv x bilateral.
TVF + chest tenderness.
Full cycle bilaterally x 2 lv
APTM

Cyanosis/Clubbing
Inspection bilaterally
Carotid -> 3 secs each. Let SP rest b/w.

JVD
3 pts + epigastric. check for costochondritis.
APTM in 45
Apex in 45
APTM + Apex in sitting

Full cycle bilaterally x 3 lv (NO lateral!).

breathe deeply when you feel my instrument.

(after 2 lvl) are you ok?
Let me help you re-tie your gown.
I am going to check your pulses on extremities.
Plz pull up your cover.
You may lower your cover now.

Abdomen:
Let me help you lie down. Let me pull out the leg
rest for you.
Plz pull up your gown. Plz let me lower the cover
a bit.
Plz point to the pain again?
I am going to check your stomach area.
I am going to listen to your stomach area.
I am going to tap on your stomach area, starting
away from the pain.
I am going to press lightly on your stomach area,
starting away from the pain.. Plz let me know if
any pain.
Any pain?
Now I will press more deeply, starting away from
the pain. Plz let me know if any pain.
Any pain?
Special Tests
I am going press in here. Plz take a deep breath
when I do. Any pain?
Now I am going to do one last test. Plz bear w/ me
if it's painful.
Any pain when I remove my hands?
Plz turn to your left side. I am going to pull your
leg backward. Any pain?
Plz turn to your left side. I am going to tap on
your back. Any pain? Any pain?
You can lower your gown now. Let me help you
up. Let me tie it for you.

Musculoskeletal:
I am going to check at your
shoulder/wrist/back/knee/hip. Plz raise your
sleeve/gown. Let me help you untie.
I am going to press on your
shoulder/wrist/back/knee/hip and nearby joints,
starting from the good side.
Any pain?
I am going to test your
shoulder/wrist/back/knee/hip movements. Plz
try your best.
Can you do this? do this? do this? Let me help you.
It might be painful for you, so plz stop me any
time if you are really uncomfortable/painful.
MRSP
Plz try to resist my strength. Can you do this? do

*SP may hold breath at one side to mimic

decrease breathing sound!

Radial + DP + PT, pitting edema at ankles.

Pull out Leg rest!

If the Pt is already lying down upon entrance,
CHECK leg rest!
Inspection
Auscultation x 4q + epigastric.
Percussion x 4q
Light Palpation.

Deep Palpation.

Murphy's Sign for Biliary Colic
Rebound Tenderness for Appendicitis +
Peritonitis + Pelvic Abscess
Psoas sign for Appendicitis + Peritonitis + Pelvic
Abscess (if Rebound is -ve)
CVA tenderness for Kidney problems
Push back leg rest!

Inspection
Palpation (3D structure)

Active ROM first, if cannot, help to determine

Passive ROM.
- Neck, Wrist, Ankle, Low Back: same ROM
- Knee, Elbow: same ROM
- Back: ROM is done w/ Pt standing.
- Hip: ROM is done w/ Pt lying down.

Muscles strength for UE/LE

this? do this?
Let me my instrument (for reflex).
I am going to tap on your arms/legs to check for
reflex.
(For Babinski) This might be tickling, plz bear w/
it.
I am going to check sensations now. Let me get
my instrument.
This is how it feels. Plz close your eyes. Can you
feel this? are they the same? ....
This is sharp, this is dull. Plz tell me what you feel.
What is this? what is this?
You can open your eyes now. Let me check your
pulses.
Special Test:
I am going to lift your arms; Can you lower your
arms slowly?
I am going to lift your leg up. Any pain?
I am going to tap on your wrist. It might be
discomforting, plz bear w/ me.
(after 7 taps) Any feelings?
I am going to pull and push on your knees. Any
pain? Any pain?
I am going to pull your knees outwards and
inwards. (Both sides)
I am going to flex your knee and juggle it around.
I am going to extend your foot. Any pain in your
calf?
Plz make a fist and hold your arm like this. I am
going to flex your wrist. Any pain in your elbow?

Neuro (+MRSP if necessary):
I am going to check your nerves in brain. Plz
follow my commands.
I am going to check your eyes. How many fingers
am I holding?
Now plz cover one eye. Tell me when you see my
fingers
Plz cover the other eye. Tell me when you see my
fingers
Plz follow my fingers w/o moving your head
Plz clench your teeth. I am going to touch your
face lightly w/ cotton. Plz close your eyes.
Do you feel this? this? and this? are they the
same?
You can open your eyes now
Plz raise your eyebrows. Plz smile and show me
your teeth.
Plz stick your tongue out and say "AH".
Plz move tongue side from side.
Plz shrug your shoulder against my hands.
Special tests
I am going to check your coordination. Plz touch

Reflexes for UE (Bicep, Tricep, Brachioradial), or

LE (Knee + Achilles, Babinski).
Get cotton swap + sharp piece. Check Deltoid for
Shoulders/Palms for UE/Foot for LE.
Sensation of UE (Palm x2+ Back of hand x1)., LE
(foot x 4 wheels).
Sharp & Dull
Radial, DP or PT.

Drop test (+ve in Shoulder dislocation)
Bilateral Straight leg test (Disc Herniation)
Tinel test (7-12 taps when extended)
Anterior/Posterior Drawer
MCL (Valgus)/LCL (Varus)
McMurray
Homan's
Cozen Test (Tennis Elbow)

Get cotton swap after washing hands!

Visual Acuity
VF x 4q + Central Scotoma
VF x 4q + Central Scotoma
EOM CN 2,3,4,6
CN 5 x 3 branches.

CN 7
CN 9,10,12
CN 11.

Finger to nose x 3 bilateral

your nose with your finger and then touch my

finger. Now the other side.
Plz flip your hand like this. Can you do it faster?
Plz stand up and walk to the door. Now, can you
walk like this?
Now I will instruct you from your back. Plz put
your feet together and hands up. Close your eyes.
I am right behind you. Open your eyes plz.
I am going to move your chin down toward your
chest. Just relax. Any pain?
If DM Pt:
Let me get the tuning fork. Do you feel this? Plz
close your eyes. Now do you feel this? are they
the same?
This is up, this is down. Plz close your eyes. What
is this? what is this?

MMSE:
Plz tell me your full name?
Plz tell me where you are.
Plz tell me what year it is now.
I am going to name 3 objects. Plz repeat after me.
Apple, Boy, Cat. I will ask you again in a minute
Can you spell "Happy" backward?
I am going to point 3 objects. What is this? this?
this?
Plz take my pen. Plz give it back to me.
If you see a trash can on fire, what will you do?
What do you think it's wrong with you?

RAM (Dyadokinesis)
Gait
Romberg.
Brudzinski
Big Toe nail bed Vibration.

Grab toe on SIDES. Position sense.

A & O x 3
Short-term Memory
Concentration
Language.
Follow commands
Judgment
Insight
(Schizophrenia (gradual onset)/Psychosis
(sudden onset): There is NOTHING wrong w/
me!)
Long-term memory

Plz repeat the 3 words I've mentioned.

SIGECAPS + Thyroid if depression.

Closing:
Ok Mr./Ms.xxxx. I would like to stress a few important points regarding your CC. First, you told me
that you have ___________, ___________ and __________. It's likely that you have medical term, which is a
problem of ____________________. (if want to give 2nd Dx: On the other hand, medical term is also possible,
which is a problem of __________________. )
I am going to arrange some more lab examinations to confirm my diagnose before we start the
treatment.
I would also like to remind you that ____________________Counselling_______________________________.
So, do you understand my diagnose? Do you have any questions?
Thank you, I will go get the nurse here and get you started on lab examinations.

COUNSELING

SMOKING
Have you ever used tobacco products?
Have you ever tried to quit?
Well I strongly recommend that you quit smoking. Because it is a major cause of cancer in

many organs. Are you interested in trying to quit?

YES: I would be happy to help you to quit smoking; we have many tools to help you
quitting and I will be with you in every step of the process. Let's set an appointment in 2
weeks from today and we can get started on that, is that OK?
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time
NO: If you ever decide to quit smoking, we have a great team of professionals that can help
you with that, whenever you feel ready, I will be here to help you.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time


ALCOHOL
Do you drink alcohol?
How many drinks do you have per week?, per day?
Do the CAGE.
I am concern about your drinking, it can lead to liver disease, bleeding problems, heart disease
and brain disease. If is a women in childbearing age: If you get pregnant, alcohol, can cause
serious problems to the baby like mental retardation.
Are you interested in cutting down your drinking?
NO: If you ever decide to cut down your drinking, we have a great team of professionals
that can help you, whenever you feel ready, I will be here to help you.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time
YES: I am glad you want to cut down your drinking. We have many tools to help you to do
that, and I will be in every step of the process. Let's set an appointment late this week and
we can get started on that, is that OK?.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.


DIABETES
Are you taking your medications as your doctor prescribed? (compliant?)
YES: I am glad to know that you take your medications as it should. I want you to know
that beside the medications there are other simple but important measures that help to
keep yourself healthy and reduce the diabetes complications. First do regular exercise and
follow the diet instructions that my nurse will provide to you before you leave
Also you should make a habit of using soft footwear when you walk, because diabetes can lead to
injury-induce ulcers on the foot.
You also should regular monitor your blood sugar, so I can adjust the dose of your medications if
needed
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.
NO: I strongly recommend you to take your medications regularly because diabetes can
lead to countless complications, it may cause vision problems, kidney disease, nerves
damage that can affect your legs, feet and arms and hands; also can affect the arteries and
vessels causing problems in your legs and arms that may end in amputation. Additionally
you will be a higher risk for developing infections, strokes and heart attacks.
If you want I can help you to remember how to take your medications.
Do you have someone who could help you take your medications?
NO: We have a social worker who might be able to arrange for a nurse to come to your home, are you
interested in that?

Also you should follow diet instructions that my nurse will give to you before you leave, and do
exercise regularly.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.


HYPERTENSION
Are you taking your medications as your doctor prescribed? (compliant?)
YES: I am glad to know that you take your medications as it should. I want you to know
that besides the medications, there are other simple but important measures that help to
control your blood pressure. First do exercise regularly and modifying your diet will help
us to manage your hypertension, my nurse will give you some diet instructions that you can
follow. Also you should regular monitor your blood pressure everyday, and write it down,
the next time we have an appointment I can look at it and adjust your medications if
necessary.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.
NO: I strongly recommend you to take your medications regularly, because hypertension
is a silent disease that can lead to countless complications, it can affect your heart, your
kidneys and your eyes; also it can lead to strokes, heart attacks and heart failure. I can help
you to remember how to take your medications.
Do you have someone who could help you take your medications?
NO: We have a social worker who might be able to arrange for a nurse to come to your home, are you
interested in that?
Also you should follow diet instructions that my nurse will give to you before you leave, and do
exercise regularly.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.


SEXUAL PROMISCUOUS PATIENT
Are you currently in a sexual relationship?
How many sexual partners do you have right now?
Who are your partners? Males, women or both?
Are you using any type of protection during your sexual encounters?
NO: Condoms reduce the risk of sexually transmitted infections, Do you think you could try
to use condoms?
NO: I understand that you may not like to use condoms, but I am concerned that you may be putting
yourself at risk for sexual transmitted diseases, you could contract HIV, herpes, chlamydia, gonorrhea,
syphilis and any other sexual infections. The complications of theses diseases include infertility,
painful infections, also can lead to other more serious infections that can damage your immune
system that is the one that help you fight the infections; also can damage your nerves and brain, and
eve cause death.
If anyone with whom you have sexual contact has a sexual transmitted disease you could share it
among all of them, including your girlfriend/boyfriend.
I hope you will consider using condoms from now on in every sexual encounter you have even if is
oral or anal sex.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.
YES: I am glad to hear that you use protection with all your sexual partners, that will help
you prevent from contract sexual transmitted diseases like HIV, syphilis, herpes, chlamydia
and any other sexual infections. And that will prevent any complications from these
infections

Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.


PATIENT WITH TRICHOMONIASIS
Your symptoms are due to an infection called trichomoniasis, a sexual transmitted disease
that has been given to you by one of your sexual partners. This infection respond well to
treatment with antibiotics and is curable. Your will also need to be test for all other sexually
transmitted diseases
Your sexual partner need to be treated as well, otherwise you will be at risk of contracting the
infection again.
Also you should avoid sexual intercourse unless you use condoms until you finish the course of
antibiotics and your partner gets treated.
Additionally you should avoid alcohol intake while you are on treatment as you may develop flushing
and headaches.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.


DOMESTIC VIOLENCE
From what you have told me I understand that at times you feel unsafe at your own home.
That sounds very frustrating.
I am glad that you came to seek attention. If you ever need some to talk to, do not hesitate to call our
office.
If ever you feel unsafe or are hurt you should seek attention from the police or appropriate
authorities; and if you do no feel comfortable doing that you can always come to us for help, and if you
wish we could arrange for someone to go to the police with you. Does it sound OK?.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.

FEBRILE SEIZURE
Mr./Ms._______, the description you provided me, make me think that your child has febrile
seizure, it is a common and benign condition in children, while some of them may have a
recurrence with fever, most of them will not have a second episode.
Almost all children will outgrow the seizure by age 5 or 6 years. Most of these seizures stop in 5 or 6
minutes and if your son/daughter/grandson/granddaughter has another episode lasting longer than
that you must take him to the Emergency Room.
I do not think your child needs seizure medications, but I will like to see your
son/daughter/grandson/granddaughter tomorrow to perform a physical exam and also do some lab
test to see why does he/she has fever, and also to reject other causes of seizures.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.


MEMORY LOSS
Talk about the differential diagnosis and the work up need to confirm the diagnosis.
The tell the patient: Until we get the test results back, I want to ask your permission to talk
to one of your family members about family and social support and safety at home, Is that
OK with you?
We have a excellent team of social worker that can help you in manage your daily activities and future
living plans in case you need it.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.


DEPRESSION
Mr./Ms.________, I believe that you might have depression, it is a common disease due to a
chemical imbalance in the brain.
I know that dealing with depression can be extremely difficult. Depression cause immense physical
and emotional stress, but we can deal it, we have a number of techniques and medications that help
with depression.
I advise that you see our counselor at the earliest, I can give you a referral, Are you interested in
talking to him?
Also we need you do some lab test including: blood cell count, electrolytes that are compounds that
are in the blood and in the cells that help the correct functioning of the body, and also we need to
measure the thyroid hormones, that are substances release by the thyroid that is a gland located in
the neck, this substances help in the correct functioning of the body; when we get back the results of
these test we will discuss the proper treatment.
If we decide to use antidepressants, you should be aware that this drugs can take up to 4 to 6 weeks
to show effects.
Have you ever feel like hurting yourself?, or Have you ever thought about killing yourself? Or
hurting other?; if you ever feel like doing any of these, you must come and see me or any other doctor.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.



LOSS OF CONSCIOUSNESS
At this time I must ask you not to drive again or use any other kind of machinery, until we
are sure what caused you to loss consciousness.
I understand that this is an inconvenient, but you might hurt yourself or others. I assure you that I
will do all I can to find out the cause of this and find the best way to help you, so you can go back to
your daily activities.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.


PEDIATRIC PATIENT WITH DIARRHEA
Mr./Ms._________, your child has diarrhea , we need to find out the cause of the diarrhea, I
need to see him/her in order to perform a physical exam and some lab tests, so please I will
ask you to bring him/her to my office today, so we can take care of him/her.
In the meanwhile you can do some measures that will help your
son/daughter/grandson/granddaughter.
First stop giving him/her cow milk.
Do you know what is an oral rehydration solution?
It is a drink that will prevent your child will get dehydrated.
Do you know how to prepare it? OK, to prepare it you need 5 cups of clean drinking water and mix it
with 6 teaspoons of sugar and half teaspoon of salt, stir the mixture. Remember to wash your hands
before preparing it.
Give your child as much of the liquid as he/she requests in small amounts, frequently and continue
feeding him/her the usually food. If he/she vomits wait 10 minutes and give the solution again.
Do you have any questions? If you get any questions or concerns, please feel free to contact me at any
time.


PEDIATRIC PATIENT WITH ENURESIS

"Mrs. Smith, bed wetting is extremely common at this age. Studies show that with each

advancing year about 10% of kids with bed-wetting will outgrow their symptoms. A
number of behavioral modifications can help decrease bed-wetting. These include not
drinking liquids in the last couple hours prior to going to bed, waking the child up in the
middle of the night to urinate, avoiding tea/coffee or caffeine containing soda with dinner
and ensuring that 'Tommy' goes to the bathroom just before going to bed. If these
modifications don't work we may consider bed wetting alarms or even medications in the
future. Do you have any other questions that I can answer Mrs. Smith?"