40-year-old woman who has become withdrawn

This case scenario will be presented in a different format in that the answers given by the
SP will be given in parentheses

In the whole patient encounter the SP will be in a most disinterested mood and will
talk in a feeble voice

The doctor should always make eye contact with the patient

The paucity of speech from the patient should not frustrate the doctor

Simulated encounter

Hello Mrs. Jones. My name is Dr. Smith. I am here to ask you a few questions and do
a physical on you. Is that ok with you. (The SP will nod feebly)

What brings you in today (I dont know Doctor. I feel a bit down)

Since when have you been feeling this way (3 months. Maybe)

Mrs. Jones; do you think that something has brought this on.( She remains silent)

Mrs. Jones; I know that you are in a lot of emotional stress. Are you willing to share
your problems with me? (The patient looks at the doctor and then away)

Do you think any thing has brought this on (I dont think so)

Do you have anybody to talk to you when you feel down (I have an aunt. She stays
far away)

Mrs. Jones. How has your appetite been of late (I dont feel like eating)

Mrs. Jones. Have you lost or gained any weight recently (my weight decreased by 7
lbs over the past one month)

How has your sleep been? (I am getting up early in the morning)

Do you feel guilty for any reason ( I dont think I am being a good mom for my
children)

Do you feel any tiredness (I dont feel that I have any energy at all. I just dont
want to get out of the couch)

Mrs. Jones Please describe your daily routine for me (I am a house wife. I do the
housework and cook for my children. Thats about it.)

Can you tell me if you have any hobbies and interests (I play violin and sing in the
choir on Sundays; but now dont feel like doing that anymore)

Do you feel that you are losing your power of concentration (mmm I dont know)

Are you forgetting things more often (Yeah. I am forgetting to pay the bills etc)

What do you enjoy most (Spending time with my children)

Do you still enjoy it (I dont feel like I want to be with any body right now)

Mrs. Jones Have you ever felt like ending your life because you felt that it wasnt
worth living? (Yeah a couple of times)

Do you have any ideas on how to do it (No)

Do you have guns or pills at home (Yeah. I have a .32 at home)

Do you feel cold when others dont (no)

Are you losing any hair (no)

Have you ever listened to or seen anything that others don't ( no)

Please do an MMSE at this juncture

Do you think that some thing is going wrong with you (Yeah)

Are you willing to get help from a counsellor (I dont know)

I can get you in touch with one. (If you feel that would help me.)

Now I need to ask you a few questions about your health in the past. Is that ok with you
(Yeah)

Have you ever been hospitalized in the past (No except for the deliveries of my
children)

Have you ever felt like this in the past (no)

Are you on any medications (no)

Do you have any allergies of any kind (none that I know of)

Do you have any problems with your urination (no)

Do you have any problems with your digestion or your bowels (I have been
constipated of late)

Have you ever had any shortness of breath (no)

Have you ever had any chest pain (no)

Have you had cough that just wouldnt go away? (no)

Now I need to ask you a few personal questions. Please do not feel embarrassed. Everything
you say will be kept confidential.

Are you sexually active (yes)

How many sexual partners do you have-A couple of them

Your sexual preference is .(males )

Do your sexual partners use condoms (Yes they do)

Have you ever been diagnosed or treated for an STD (no)

Have you ever been tested for HIV (no)

Now I need to ask you a few questions about your family so that I can get a clearer picture
of your health

Are you married (I was. Got a divorce 10 years ago)

Are your parents living (no. They died of old age)

Has any one in your family been diagnosed with a psychiatric disorder (no)

How many children do you have(2. The elder one is 14. The younger one is 11)

Now I need to ask you a few questions about your lifestyle.

Do you use tobacco (no)

Do you drink any type of alcoholic beverages? (Yeah. I have 2 shots of scotch on the
rocks. Been doing so for the past 10 years.)

Do you use any recreational drugs (no)

Do you drink coffee (Yeah. One cup every morning)

Now I need to do a physical on you. Please excuse me for a few seconds while I wash my
hands

I am going to check your thyroid gland (Not palpable)

I am going to check your reflexes (2+)

I am going to check your pulse now

I am going to listen to your heart and lungs now.

Thank you Mrs. Jones for your cooperation.

I am going to sit down and tell you what I think so far

I feel that you are having an episode of depression though I wouldnt definitely say
it before the results of some tests that I am going to run on you.

I am going to order a blood test on you to find out if you have any problems with
your thyroid. After the results come in I would sit with you again and then we can
discuss how we can make you feel better.

Is there anything else that I can do for you?

Differential Diagnosis

Depression

Hypothyroidism

Occult carcinoma

Workup

T3 T4 TSH

CBC with differential

Urine and serum toxicology screen

52 O/F with a Complaint of hot flashes

Vital

B.P 140/80

Pulse 80/min and regular

RR is 16/min

Temp. 98.80F

Communication and Data gathering

Hello Mrs. Lewis ; I am Dr. Jones (hello Dr), good morning (good morning Dr), nice to
meet you (nice to meet you Dr)

What brings you in to day (I dont know Dr; I feel some hot flashes that seem to run
through me)

Since when has this started ( around 3 months ago Dr)

How often do these hot flashes come (About 10 times daily )

Do you feel anything else when these flashes occur (I sweat a lot and I feel my
heart racing)

Do you know that you are going to get a hot flash beforehand-I mean do you feel it
coming even before it really starts. (Yes Dr-sometimes I do, It some times even
disturbs my sleep)

How are you feeling during most of the days-I mean what is your mood like during
the last 3 months. (I dont know Dr. I seem to be dull some times and some times I
have these uncontrollable temper episodes and some times I just want to be left
alone. I just dont feel on top of things. This whole thing is driving my husband
crazy)

Do you feel any burning or pain when urinating (yes I do and I feel that I have to
rush to the bathroom some times and I wake up a lot during nights to go to the
toilet)

When did you have your last menstrual period Mrs. Armstrong (about a year ago)

Do you have any problems with your bowels (no)

Have you had any thyroid problems in the past. (yes Dr, I had a goiter 10 yrs back
but it was operated and removed)

Do you have any other problems like high blood pressure, diabetes...(no)

Make eye contact and then say Mrs. Armstrong I am going to ask some sensitive
questions. It might be embarrassing to you, but it is in your best interests that we
have to go ahead with these questions and please feel free.

How has your sexual life been of late (I dont know Dr. I get a lot of burning
sensation and I generally dont show much interest because of the pain even though
my husband wants to do it)

Is he supportive (Yeah I guess but he is frustrated with the way I have been
behaving)

Do you have any other problems for which you have taken consultation or medication
(No Dr This is the first time that I am sick )

Have any of your relatives been diagnosed with Breast or uterine cancer (Yes Dr my
sister had one breast removed for breast cancer)

Have you ever had any swollen and painful limbs, any blood clots in your legs.? (no)

Have you ever had any pain in the legs or back (for osteoporosis).? (no)

Do you smoke (no)

Do you drink any type of alcoholic beverages (no)

Do you have any allergies (no)

Do any of your family members have a history of clotting disorders (no)

Examination

Do a Heart , lung, and abdominal exam very quickly and superficially.

Check for muscle pain in the back

Check for hyperactive reflexes

Counseling

Tell the pt that the most probable diagnosis is menopause

Offer help to educate the husband about the possible diagnosis

Tell her that she is a candidate for HRT even though her sister had breast cancer

Inform her about the adverse affects of HRT

Offer her estrogen cream for the vagina to ease her dyspareunia and her dysuria

Inform her that she needs to supplement Calcium in her diet to reduce the risk of
osteoporosis. Inform her of the beneficial effect of adequate wt bearing exercise.

D.D for this Case

Menopause

Hyperthyroidism

Occult malignancy

Factitious disorder

Chronic fatigue syndrome

Work Up

CBC with ESR

Thyroid profile

Serum FSH and LH

DEXA

Pap smear

70 Yr. O/F Complaining of Forgetfulness

Vitals

Temperature 98.6

pulse 76/min, regular

B.P 150 /85

RR 16/min

Make a Differential Diagnosis

Alzheimer's Disease

Vascular dementia

Normal pressure Hydrocephalus

Vitamin B12 deficiency

Hypothyroidism

Masked depression

Chronic Subdural Hematoma

Simulated clinical encounter:

I am giving only the questions to ask not the manner in which they should be asked. For that
I think you will have to read the history gathering section of this site.

Hello Mrs. Eve; I am Dr. Jones; how are you doing today. If you can hear me
please nod.

How are you feeling nowadays. Are you feeling sad or lonely

Do you find any difficulty while walking

Do you have any problems driving to the grocery store

Do you have any problem eating food, or in making meals for yourself

Do you have any trouble with your toilet habits.

Do have any problems while shopping and housekeeping

Are you finding any difficulty in managing your accounts

Have you noticed any wt loss over the past few months.

Do you have any problems with sleep.

How are your bowel habits

Do you have any spells of dizziness or feeling of a pounding heart

Did you notice any cold or heat intolerance

Did you have any medical problems in the past

Do you have somebody to take care of you in case of an emergency or do you

want me to get you in touch with a social organization

Please describe your regular diet for me

Are you having any problems with your memory

Are you able to find your way through your house

Do you smoke

Do you drink any type of alcoholic beverages

Are you sexually active

Have you ever had any sexually transmitted diseases

Do you have any family members who had a hereditary medical condition.

Examination:

Do the following questionnaire as part of the mental status exam

Mrs. Thomson, Can you tell me your full name

Can you tell me what day it is today

Can you tell me where we are now

Please spell the word WORLD back for me

Please repeat the three objects that I a going to tell you right now. I want you to
tell them to me right away and then again after some time; so please remember
them

Please put your left hand on your right hand and bring both hands towards your
chest and then back to their original position.

Do a focused neurological exam

Do the get up and go test

Do a fast heart, lungs exam

Do not forget to do a fundoscopy

Counseling:

Tell her the diagnostic possibilities workup and prognosis

If you suspect that she has Alzheimer's; Ask the pts permission and then tell the pt
about the importance of structured home environment and the precautions to be
taken to avoid falls.

Explain to the pt the necessity of being regular in taking her medication. See to it
that the pt understands her problem ,

Ask her about her social support and offer any help

D.D for this Case:

Alzheimer's Disease

Vascular dementia

Normal pressure Hydrocephalus

Vitamin B12 deficiency

Hypothyroidism

Masked depression

Chronic Subdural Hematoma

Work Up:

CBC with differential

CT san of head

T4,T3 TSH

S.Creatinine and S. electrolytes

Syphilis serology

10

50 Yr. old diabetic male came for medication refill

Vitals

BP-135/70

Pulse- 73

R.rate-16

Temp- 98.7

History taking:
Please remember that you need to use appropriate transitions sentences. This is quick
glance of questions how to proceed.

When were you diagnosed with diabetes?

Are you currently taking any medications for diabetes? (yes, glyburide)

Are you taking your medications regularly?

Do you think that your medicines are controlling diabetes effectively?

Have you ever taken insulin?

How often do you check your blood sugar? or Are you checking blood sugar regularly
according to your previous physician advice?

How has your blood sugars been lately? I mean can you please tell me how high / at
what range were they?

Do you have any problems that you would like to tell?

How is your vision? Do you think is there any change in vision lately?

Do you feel any abnormal sensations in legs like pins or needle prick sensations, any
tingling or numbness?

Have you ever had any chest pain?

Do you have any breathing problems?

Are you sexually active? Do you have any problems in sexual intercourse?

How are your bowel habits?

Do you have any problems with urination?

Past History

Are you allergic to anything?

Have you ever been hospitalized for diabetic complications or for any other reason?

Are you taking any medications besides diabetic drugs?

11

Do you have any other medical problems like high blood pressure?

Do you smoke?

Do you drink alcohol?

Do you exercise regularly?

How is your appetite? Have you lost or gained any weight lately?

Examination

Look fundus for DM retinopathy.

Test sensation in legs.

Auscultate for carotid bruits.

Palpate precordium for PMI. (Cardiomegaly)

Auscultate heart.

Check distal pulses in at least two places

Investigations

CBC with differential count

Blood glucose

HbA1C

BUN and Serum Creatinine

Lipid Profile

Key point: Even if the SP is wearing shoe or socks, please don't forget to take them out to
examine the feet!!

12

20 Yr. O/F Complaining of vaginal bleeding

Vitals:

B.P - 90/60

Pulse - 90

R.rate - 16

Temp - 98.8

Make a Differential Diagnosis in your mind

Regular menses

Abortion

Pregnancy

Ectopic pregnancy

H. mole

Trauma.

Simulated encounter:
Please remember that you need to use appropriate transitions sentences. This is quick
glance of questions how to proceed.

When did the bleeding start?

Was it all of sudden in onset or gradual?

Can you describe more about the bleeding. I mean is it a bright red blood or clotted
blood.

Is it a pure blood or does it contain any tissue like substance (i.e. Molar pregnancy
--> Grape like tissue)

Has it been a continuous flow or spotting?

What were you doing when it started? I mean were you sleeping or having sex?

Do you have any other symptoms that you would like to tell besides bleeding, like
abdominal pain, fever, vomiting.?

Have you ever been pregnant?

When was your LMP?

Can you describe more about your menstrual cycles. I mean how was the flow? How
many pads do you use per day? How many days? are they regular or irregular?

Have you had any history of abortions?

13

Have you ever been tested for STDs?

Past History

Have you ever had any history of bleeding or hospitalizations for bleeding?

Sexual History

Are you married

If yes

Do you have any other sexual partners? (yes)

Do you use any means of contraception?

If no

Do you have any other sexual partners? (yes)

Do you use any means of contraception?

When was your last sexual contact?

Social history

Do you smoke?

Do you drink alcohol?

Do you use illicit drugs? (cocaine may cause painless 1st trimester bleeding)

Family history

Do you have family history of any bleeding disorders?

Do you have any family history of multiple abortions.

Examination

Look for other sites of bleeding. (nose, gums)

Tell that you want to check for orthostatic hypotension.

Auscultate abdomen .

Percuss abdomen for liver span.

Palpate abdomen superficially.

Palpate abdomen deeply.

Check for rebound tenderness.

Ask to do pelvic exam.

D.D for this Case

Regular menses

Abortion

14

Pregnancy

Ectopic pregnancy

H. mole

Work Up

Pelvic examination

Pregnancy test

CBC and ESR

Transvaginal ultrasound

TSH.

Serum -HCG levels

15

Door way information:

Case: 56 year old Scott comes with left sided shoulder pain, vitals were normal.
Simulated encounter

Once you see the doorway information all you need to do is just note the name of
the pt. Take 15-30 seconds at door way to make a mental checklist of differential
diagnosis of shoulder pain. There is no point in spending more time.

First knock the door

Make comfortable eye contact - empathic

Patient on the table will be in awkward position in pain. Don't change position of the
patient, stand in front of the patient. Make two to three feet distance from
patient; you adapt to his position.

We advised to stand instead of sitting.

Say hello Mr. xyz nice to meet you. I am here to ask you some question's and take
your physical ( in a slow empathic tone)

Don't shake his handbecause he will be supporting his painful hand with the
opposite hand. (You will not get points of shaking and you will loose point of causing
pain to patient)

Patient says this pain, I cannot even sleep.

First ask an open ended question, Mr. Scott can you tell me something more about
your pain. He will answer some aspects of pain like location, quality and some others
of LIQOR AAA, make a note in the mind, and dont ask them again. If you are caught
asking again tell him that you were just checking.

Ask all pain questions (LIQOR AAA) plus functional impairment (ask questions about,
occupational impairment, sleep, help at home). Remember all three will be there in
the check list.

The patient will respond to all LIQOR AAA questions. Ask specifically whether he
took any medications and any relief with them. He will say the pain was becoming
better after he took Ibuprofen.

Always ask the precipitating factor of pain: SP will say that he fell down on the
stairway at night while going down to kitchen to drink water

Then ask about deficits:

16

Do you have tingling, ......(pause) or numbness (no)

Did you notice any swelling/redness after the fall (no)

Do you have pain in any other part of the body (Yes; little at the palm)

Are you able to use your arm (No; because painful)

Do you feel any weakness (No, only pain)

PMH:
The ask PAM HUGS FOSS Now I need to ask you a few questions about your health in the past. Is that ok with you
(Yeah)

Ask the second open ended question "How has your health been until now"

Have you ever had any problems with your shoulder (Yes, Injury to left arm 3 yrs
back and had a humerous fracture)

Do you have any other medical problems ( Yes I did have acid peptic disease)

Are you allergic to anything ( Yes; I am allergic to penicillin)

Have you taken any medications ( Yes only Ibuprofen for pain)

Do you have any problems with your digestion or your bowels (I have been
constipated of late)

Do you have any problems with your urination (no)

Now I need to ask you a few questions about your family health. Is that Ok with you? (Yes)

Are your parents living (no. They died of old age)

Has any one in your family members have medical problems (Pulmonary fibrosis to
brother and father)

Now I need to ask you a few personal questions. Please do not feel embarrassed. Everything
you say will be kept confidential.

Are you sexually active (No)

Now I need to ask you a few questions about your lifestyle

Do you use tobacco (no)

Do you drink any type of alcoholic beverages? (Yeah. I have 2 shots of scotch on the
rocks. Been doing so for the past 10 years.)

Do you use any recreational drugs (no)

Here ask the another open ended question for social and occupational history.

17

You can ask like this 'tell me something about your life at work and home' (Cannot go
to party today because not able to drive)

Examination:

After your history.ask him like " All right; thank you for being cooperative.. now I
would like to take your physical; before going physical is there anything you want to
tell me before I start your physical. I would be happy to answer" ( Remember he will
tell you exactly like this ' Please be gentle with my arm doctor). This is the time to
grab one more point for you. Right away console him like "I know that you are in pain,
I will try to do my exam as gentle as I can, is that sounds good.' You will see the
relief on face of the patient and an importance of an open ended question. This
question will help you to ask and counsel the patient more efficiently.

'Please excuse me for a few seconds while I wash my hands';

Always start with local examination i.e. painful shoulder

Expose the joint properly while draping th other parts.

Before inspection say that you are looking for redness and swelling, dont just look
he should know that you are looking. Palpate and compare both joints.

Palpatefor swelling, warmth, and crepitus gentlytell him first that you will be very
gentle. Say sorry if he complains of tenderness during the examination.

Most of the times SP will have tenderness on anterior part of shoulder joint.

Check range of motion (ROM) in abduction, adduction, flexion, extension, internal

and external rotation (Obviously SP will have restricted abduction beyond 60
degrees i.e. he will complain of pain after 60 degrees). Always adduct the patient's
arm across the chest (crossover test).

Check reflexes, pin prick sensations

Check the opposite arm

Check hand in detail

Just see the legs very quickly

Listen heart and lungs in 10 to 15 seconds.

Counseling:

Explain the probable diagnosis, follow-up after investigations, and the availability of
physiotherapy.

18

Diagnosis

Shoulder dislocation

Shoulder fracture

Rotator cuff tear

Subacromial bursitis

Ligament sprain

Work up

CBC

X-ray of shoulder joint two views, including elbow

X-ray hand two views

MRI of shoulder

ANA and Rheumatic factors

Note: You will get the case exactly similar to this in the real time exam. Please don't ask
how come. The important thing that you need to remember from this case is "You have to
ask all PAM HUGS FOSS for all the cases no matter what the complaint is because they will
have those in the check list. They see whether you are asking all the aspects or not. Believe
me 'Ask PAM HUGS FOSS for all the cases, you will pass.'

19

Doorway information

A 40 yr old white female (Mrs. Kelly) came for obesity evaluation

Her vitals are BP - 150/90 mm of Hg, HR - 68/min, RR - 16/min and temperature Normal.

How do you approach this patient?

Knock the door and enter the room with a smiling face.

Hello Mrs. Kelly, this is Dr. Robert walker, good morning; nice to meet you. (nice to
meet you doctor)

How are you doing today? (Good)

Excellent. So what brought you in today? ( You know doctor I am really worried
about my weight; these days I am really gaining weight, it makes me worried)

I am glad that you came here for evaluation. We will try to work together and try to
fix it, ok? (yes doctor , thank you)

I know you are concerned about your weight gain; could you please describe me little
bit more about your problem? (I don't know anything specific doctor but I am
concerned about my weight)

[Note: Remember they reveal only few things. They really don't tell you until you ask
specific questions. So you have to start asking relevant questions. Before you ask, make a
checklist of problems associated with obesity.]
Here are the common problems associated with obesity
1.

Type II diabetes

2. Heart disease
3. Stroke
4. Hypertension
5. Osteoarthritis
6. Sleep apnea
7. Breathing problems
8. High blood cholesterol
9. Gall bladder disease
10. Increased incidence of cancer like endometrial, colon, postmenopausal breast
cancer etc.

20

11. Increased surgical risk

12. Menstrual irregularities
13. Stress incontinence (due to weak pelvic floor muscles)
14. Psychological disorders like depression
15. Psychosocial difficulties like social stigmatization

So how do you ask all these; start like this

Ok Mrs. Kelly I am going to ask few specific questions about your present and past
medical health. Just let me know if you have any problems. Ok (Oh! sure Doc)

For how long have you really been concerned about your weight gain? ( May be from
the past 6-7 months)

What do you think is the major reason for your obesity? (I really don't know)

How is your appetite? ( It's too much Doc; I want to stop eating junk food but I
cannot control)

Ok for how long have you been having this increased appetite? ( For the last 2-3
yrs)

Do you have any problems with your breathing; especially in the nights? (No)

How is your urination? (Pretty good), I mean did you notice any increased frequency
(no); have you ever leaked without your knowledge (no)

Do you have any problem with your bowel movements? (They are pretty regular)

[Note: You have to consider hypothyroidism and Cushing's syndrome as a differential

diagnosis in a case of obesity. "Have you ever had problems adjusting to
temperatures?"( No). "Have you been on any steroid medications for any reason?" (No). You
already know that she did not have any problems with bowel movements (constipation in
hypothyroidism)]

Did you notice any joint pain especially at the level of hips or knees? ( Some pain in
both knees)

Have you ever been diagnosed with high blood pressure (no). When was your last
visit with your primary care physician ( A couple of years ago )

Have you ever had any heart problems? (no)

Have you had any history of stroke? (no)

Have you ever been tested for diabetes? (no)

21

Ok Mrs. Kelly when did you check your cholesterol level last time? (I think 5 yrs ago
and it was slightly elevated and after that I did some exercises, but it did not really
help much)

Have you had any surgeries in the past? (Yes Doc, cholecystectomy 9 months back)

Are you allergic to any thing? (no)

Ok Mrs. Kelly now I would like to ask you few personal questions. Everything you say will be
kept confidential. (Ok Doc sure)

How has been your menstrual cycles? (They have become irregular these
days, but they are not bothering me much.)

From how long have you been having these irregular periods? ( For the past
2-3 yrs, it seems everything started from the past 2-3 yrs)

When was your last menstrual period? (20 days ago)

Are you sexually active? ( This is one more problem for me doctor, these
days I don't feel like having sex)

How is your mood Mrs. Kelly? Are you feeling Ok? ( I am feeling a little bit down
these days)

Do you smoke Mrs. Kelly (No)

Do you drink any type of alcoholic beverages ( occasionally 1-2 beers in the
weekends)

Are you taking any prescription medications? (no),

Do you take any over the counter medications (no)

Do you take any recreational type of drugs (no)

Can you describe me more about you diet? I mean what is your diet usually consists
of? (Pretty much cheese and junk food doctor, some times fruits)

What do you do for your living? I mean do you work? ( yes doc I am working as a
desk clerk)

Examination:

Just do some focused lung, and heart examination.

Check the thyroid gland.

Check extremities for any edema.

Counseling:

22

There is a possibility of thyroid problem (even Cushing's syndrome if the patient is

on steroids) in your case even though very unlikely, first let me run some tests on
you then we will sit together and go over the treatment options available.

Mean while try to restrict fatty food and start regular exercise.

Most people will not succeed if they radically change their current eating and
cooking habits; however, you will probably have greater success if you try to modify
only one aspect of your eating habits at a time. Eventually, you will find yourself
eating a healthier diet.

If you would like more specific advice for diet changes there are many excellent
books available, or you may wish to ask for a formal consult with a dietitian.

Investigations:

CBC with Differentials

EKG

Thyroid panel

Urine cortisol levels

Lipid profile

Diagnosis:

Obesity

Hypothyroidism

Cushing's syndrome

Note: This is a quick glance of questions that you have to ask in a case of obesity. Don't
forget to use appropriate transition sentences and open ended questions.

23

A 69 yr old male with terminal cancer requesting for pain medications

If you get a case like this you really have to show empathy and care.

Start with formal greeting and place a hand on the patient shoulder, make an
eye contact then the ask an open ended question "Mr. XYZ please tell me what
bothered you to come in here? (I am having pain in my epigastrium)

I have been informed that you have been diagnosed with cancer. Is that
correct? (yes)

Could you please tell me more about your cancer? (I have pancreatic cancer,
diagnosed 3 months back)

I am very sorry to here that (Thank you doc). I know its very difficult, I can
understand what you are going through. But I want you to know that I am there to
help you if you need anything and make you feel comfortable. ( Thanks you very
much)

Can you please explain me little bit more about your pain? How severe is the pain
in a scale of 1 to 10? Do you think there is anything that makes your pain less?

Do you have pain anywhere else? (Some times my back hurts)

Are you using any medications for your pain especially any narcotics or
morphine? ( not much)

Do you have any other complaints other than pain? ( I am feeling tired most of
the time)

How is you appetite? ( Its very much decreased), Have you lost any weight? (yes;
around 1-12 pounds in 3 months)

Do you have any fever? (no)

How are your bowel movements? Do you have any problem urinating?

How is your mood? ( not good doc, I feel depressed)

Have you had any thoughts of ending your life? (not really so far)

Can you please tell me about your home situation? ( I don't have anyone doc, I
live alone)

Do you have any one to help or support you like any friends or family members
( I have few close friends, yes they certainly help if I need)

24

My. xyz I will certainly help you in relieving your pain. I will prescribe some narcotics like
morphine to relive your pain. I would also like you to be aware of certain things which will be
necessary at some point in your life. I am very sorry to ask you these questions but I hope
you understand the situation. (Thank you doc, don't worry ask me)

Where do you want to live? Do you want to stay at your home or at nursing
home? (I want to stay at home)

Are you aware about "hospice"? (not much) Ok let me explain about hospice.
Hospice care is a choice you can make to enhance your quality of life in a terminal
stage. You can also choose to die at home with the support of family, friends, and
caring professionals. Over 90% of hospice care is provided at your home. The
advantage of Hospice care is that the providers have the skills and resources to
permit you to live as pain-free, as comfortable, and as full a life as possible. In
addition to providing pain relief Hospice care emphasizes comfort measures and
counseling to provide social, spiritual and physical support to you and your family. All
hospice care is under professional medical supervision. So I strongly advise you to
take Hospice care. ( Thank you very much Doc, You relieved most of my tensions)

Ok, are you aware of advance directives? (no not much doc). Ok, an "advance
directive" or a "living will", will enable you to give your opinion on how you should be
treated when you reach the terminal stage of the disease and not in a state to make
a decision or you can give the right to take that decision to a loved one who you
think will take a wise decision for you. Do you understand what I am saying? (yes
doc)

Do you have any other questions? (No not much doc)

Examination:

Auscultate and palpate the abdomen.

Quick auscultation of the heart and lungs.

Look conjunctiva for pallor or jaundice

If you do this much this is more than enough for the exam.

There is no single way to give counseling. This is an example for you to give
counseling but bear in mind its not necessary that you follow this exactly word to
word. This just gives you an idea to help you build up your own way in which YOU ARE

25

COMFORTABLE. It is fine as long as you show that you are sensitive, supportive and
conveying necessary information.

You don't need to write investigations or differential diagnosis if the problem is

purely cancer.

26

A 62 yr old male with confusion

Evaluation of confusion has very broad differential diagnosis. So narrowing down

to differential diagnosis depends on the SP's complaints.

Start with formal greeting and ask, "What brought you in today?" (You know doc
actually I don't think I have any problem but my wife says I am very confused these
days)

How long has she been concerned about this? (I think from the past 2-3
months)

Is she saying that you are confused all the time or is there any specific time or
related specific situation? (All the time Doc)

"I understand that you are not much concerned about this. But let me ask few more
questions to find out what exactly is going on. Is that ok with you?" (Sounds great Doc)

Do you have any problems with your memory? Or has she ever complained about
your memory? (No)

Do you feel any weakness in the extremities? (No)

Do you feel abnormal sensations like tingling or numbness in the extremities?

(No)

Do you feel dizzy? (No)

Have you ever had any fit like movements or seizures? (No)

Do you have any history of head trauma? (No)

Do you have any fever? (No)

Do you have any headache? (No)

Have you ever passed out? (No)

Can you please describe me about your typical day, like your routine activities of
daily living?

[Note: Please know the Katz Activities of Daily Living (ADLs) - "DEATH" i.e. Dressing,
Eating, Ambulating, Toileting, Hygiene and Instrumental Activities of Daily Living (IADLs) "SHAFT" i.e. Shopping, Housekeeping, Accounting, Food preparation, and Transportation.]

How is your bowel habit? (They are pretty good)

How is your bladder function? (Good)

27

Did you notice any increased frequency of urination? (Yes, I have this problem
from long time; I usually pee little bit more)

Do you have any history of diabetes? (Yes), When were you diagnosed with
diabetes? (About 25 years ago), Are you on any medication? (Yes I am on insulin), Do
you know how much insulin you take daily? (Usually my wife or my daughter gives
insulin shots), How often do you check your blood sugar? (Rarely like once or twice in
a year), Is your blood sugar under control? (Some times), Have you ever been
admitted in the hospital for diabetic related complications? (No) or for any other
reason? (No, Never)

Do you have any other medical problems? (Yes I do have high blood pressure),
For how long? (Same as my diabetes), Are you taking any medications for that? (Yes;
I am on atenolol 25 mg twice daily; I guess), For how long have you been on these
medications? (Around 18 years), How often do you check your blood pressure? (Once
or twice in a year), Is your high blood pressure under control? (Not always, only
some times)

Have you ever had any heart problems? (No) Have you ever had stroke? (No)

Other than insulin and atenolol are you taking any other medications? (No)

OK, Are you allergic to anything? (Yes; to penicillins)

[Note: Everyone will have allergic history, please ask about the allergic history, you don't
have to get into details about the allergy if the case is not related to that, as in this case.]

Ask about the family history?

Are you sexually active? (No)

Have you ever been diagnosed with sexually transmitted diseases especially like
syphilis? (No, never)

Do you smoke? (No)

Do you drink any type of alcoholic beverages? (no)

Do you take any recreational drugs? (no)

Can you please describe about your dietary habits? ( I usually eat beef and some
fruits, It's just a regular diet Doc)

If you ask this much in the history that is more than enough. You may not get enough
positive history for any particular diagnosis. So don't worry.

28

Examination:

You have to do Mini mental status exam (MMSE) - This kind of people usually
have normal MMSE.

You must do fundoscopy

Check gait, muscle strength, reflexes, sensations, and very quick cranial nerve
examination.

If you have time auscultate heart and lungs.

Most of the times people wont get sufficient time because of the MMSE and CNS exam. Do
as much as you can very fast. Once again practice repeatedly otherwise its very difficult to
manage in the exam.
Investigations:

CBC with differential

Serum electrolytes or Basic metabolic profile (BMP)

EKG and 24 hr Holter monitoring if there is any history of spells

Carotid doppler

CT head

Urine toxicology screen if you suspect any drug abuse

Differential diagnosis:

Insulin induced hypoglycemia

TIA

Multi infarct dementia

Electrolyte abnormalities

Substance abuse or Drug intoxication

Alzheimer's dementia

We don't think you will have enough time to give counseling. But any way always ask "Do you
have any questions?" and formal "closing the encounter". Explain about the importance of
tight blood sugar and hypertension control.
"I am sorry to here that your blood sugar and blood pressure are not under good control.
Controlling blood sugar requires determination. I will give you a treatment plan, which
advises on right diet, exercise, and using the medication. High blood pressure could indicate
that your blood vessels are having trouble. Hypertension/high blood pressure could

29

complicate a diabetics problem. It could cause stroke, affect the functioning of the heart
and even the kidneys. Again regular exercise, reduction of weight (if the patient appears
over weight), limiting salt in your food could help in keeping hypertension in check. I would
strongly advise you to take regular health maintenance examinations and tightly control your
blood sugar and blood pressure. What do you say Mr. xyz?" (Sounds great, Doc)

30

A 25 yr old male for pre-employment check up

You may get this kind of cases as either "Pre-employment" checkups or as an
"Insurance checkup". They will tell you everything what you have to do some may be
asked to fill up a FORM (It will be provided to you). In case you were not provided with
a form you will have to take a simple general history. Most of the times you will be
asked to do physical examination only.

If they want you to do any specific examination, do that and do all the things
that are mentioned in the FORM first. You can fill the form after coming outside. In
case if the SP asks about the form tell him that you will post it to his home. After
you finish "filling"( examining ) the form ask

"Do you have any questions?" If he

asks for some thing then ask the relevant history. If they don't tell anything
specifically you can start taking history in brief. Ask cardinal symptoms of each
system.
Do you have any cough? (No), Do you have any problems with

breathing (No)

Do you have any chest pain? (NO)

Do you have any headache? (No) Do you have weakness in th

extremities? (No)

How is your bowel habit? (Pretty good)

How is your bladder function? (Good)

Then you must ask PAM HUGS FOSS

Please do not forget to ask about Allergic, smoking, alcohol and

sexual history.
Here is the sample of the form that you might get. It may not be exactly
like this its just to give you an idea. You may get some of the components of
this form.
If they ask you to measure blood pressure (on the form/doorway
information) you have to measure. This is different from all other cases
where you need not to check blood pressure. After finishing the case you
just have to fill out this form. You don't need to write any history (If they

31

don't ask) or things that they have not asked you. All you have to do fill out
the form.
Height
Weight
Blood pressure
Pulse rate
Lung auscultation
Heart auscultation
CNS reflexes
Abdomen
Spine examination

32

Case of Abuse:

There are many ways to ask direct questions that elicit a response about domestic
violence or abusive relationship. No single question is right as long as you are
sensitive and supportive.

In real life many battered women may hesitate to initiate information about abuse,
but are relieved to answer when some one asks. That is why they (CSA exam) expect
you to know this kind of cases and usually you may get a case like this. So know
everything how to ask and elicit a proper history.

If you are suspecting a domestic violence or a case of abuse ( Ex. Women with
bruising or some pts with depression) you can start with a good screening qt like this

"I don't know if this is a problem for you, but because so many people we see are
dealing with abusive relationships, I have started asking about it routinely. Are you
currently in a relationship where you are physically hurt, threatened or feel afraid?"

If the chief complaint itself is an abuse you can ask direct questions like
o

"What happened? How were you hurt?

"Were alcohol or drugs involved? How ? By whom? or Does your partner use
drugs or abuse alcohol?"

"Has a weapon ever been used in an attack on you?"

"How long have you been in this abusive relationship? Has it happened ever
before? Are you afraid it will happen again?"

"Has your partner ever made you have sex when you didn't want to?"

"You have mentioned your partner looses his temper with you. How are things
between him and your children?"

"Have you ever left home? When? if not, have you wished to leave? What
has prevented it?"

"Are you planning to leave/divorce your partner?"

"Has your partner ever threatened or tried to commit suicide?"

"Do you, yourself, think of suicide as a way out of the relationship?" If the
answer is 'yes' ask "Do you have a plan or method by which you would kill
yourself? or partner?"

"Do you have an emergency plan if needed?"

33

"Are your family or friends aware of your situation?"

During the whole encounter tell her repeatedly that she does not deserve to be
beaten. Battering is against the law.

Examination is basically examining the injured (painted parts!!) parts and quick
auscultation of heart, lungs (no percussion unless pt has a big bruise over the chest
and having breathing problem) and abdomen (do palpation also).

Counseling:

Counseling is a major part if you get a case in the exam.

Create a safe space by assuring her that you will do everything possible to maintain
her safety. Assure her that her medical condition will be treated appropriately, and
that she will not be forced to do anything against her will.

Tell her that children are cared for and safe (if present).

Assure her confidentiality. Explain her that only with her signed consent will her
medical records be released to any other source.

Tell her that violence never ends on its own and that the violence almost always
escalates in severity and frequency over time, and that the only way to end it is to
get away from the batterer.

Always be respectful and non-judgmental; Say "I believe you, it is not your fault, you
are not crazy, you are not alone, help is available for you."

Before she/you leaves ask "Do you think is it safe to go home? Do you have a safe
place to stay? Would you like to speak with a domestic violence counselor?"

Note: If you notice multiple bruises (nice painting by CSA people) and the patient did not
give any history of abuse, ask like this "I notice you have a number of bruises. Did some one
do this to you? It looks like some one hurt you. Can you please tell me what happened to
you?"

34

Patient with Insomnia:

Insomnia has numerous, often-concurrent etiologies, including medical conditions,
medications, psychiatric disorders and poor sleep hygiene. Sleep apnea should be also
considered in the differential diagnosis. So the evaluation usually requires detailed history
taking. This is one of the most common problems in the USA and its good to know about this
case for CSA.
Starting encounter with the SP:

What brought you in today? (I have problem with sleep Doc)

Can you please tell me more about your problem? (I use to work as truck driver
during night and now I switched to day time work, since then I am having problems
with sleep, I think this all is due to the shift of work. Please give me some sleeping
pills Doc)

I understands that your problem might be due to change of working schedule

but there are some other common things and conditions that can cause sleep
problems, which can be easily treatable if we can find. So I need to ask few more
questions about your sleep patterns, your general condition and some other things.
Is that ok with you? (Sure go ahead Doc)

How long have you been having problem with sleep? (Around 3 - 4 weeks)

Do you have problems with falling asleep? (Yah most of the times)

Do you have any problems with staying asleep? (Yah some times)

Do you have problems with waking from sleep? (No)

You said that most of the times you are having problems with falling asleep.
When do you usually go to bed? (between 8 to 9 PM), How much time do you take to
fall into sleep?(1 to 2 hours). What do you do before you go to bed? I mean some
people do exercise in late evening and drink alcohol before go to bed. Do you do any
exercise like that? (No), Do you take any alcohol before you go to bed? (Yah), How
much do you take? (A couple of beers usually), Do you smoke before you go to bed?
(Yah mostly after having dinner), Do you take caffeine or excess coffee before go
to bed? (Not really)

Do you watch television while lying on the bed? (Yah usually)

35

You said you also have some problems staying asleep. Do you wake up several
times during night? (Not several but 2-3 times and if I wake up it takes awhile to go
to sleep again). Ok you said you wake up 2-3 times in a night, do you have any idea
what might be causing it? I mean do you wake up to urinate many times or any
problems with breathing or coughing? (No) [If you are asking several question always
give a pause to each question]

Have you or any of your family members noticed frequent movement of legs
during your sleep? (No, not that I know of)

Do you have pain anywhere? (No)

How is your mood? (Pretty good) [If the SP appears depressed you have to ask
all depression questions. But it is very unlikely to get a case with 2-3 problems like
depression, shifting of work etc, as it s very difficult to manage in 15 minutes]

How are your bowel habits? (Pretty good)

How is your bladder function? (Pretty good)

Do you have any other medical problems? (No, I am pretty healthy)

Have you ever been hospitalized for any reason? (No, never)

Do you have any allergies? (No)

Are you taking any prescription medications? (No), Any over-the-counter

medications? (No), Are you using any recreation type drugs? (No)

Are you sexually active? (Yes), Do you have any problems with sexual
performance? (No)

You said you have a habit of smoking and drinking alcohol? How long have you
been smoking? (15 yrs). How many cigarettes do you smoke in a day? (5to10), How
long have you been drinking alcohol? (Same like smoking), How much do you drink per
day? (As I said 2-3 beers a day)

Do you have any stress at your work? (No)

Ask about family history.

[Note: Some times the major cause of sleep disturbance in middle-aged women is the
menopause-related "hot flush." Recent studies indicate that nearly every hot flush
promotes an arousal from sleep. So please keep this in mind if you get a female patient of
menopausal age.]

36

Examination:

Check thyroid

Auscultate lungs and heart quickly

Diagnosis:
Circadian rhythm sleep disorder

Counseling:

"Based on your history I think your problem is most probably due to a

combination of multiple factors. Obviously shift of work is a consideration but at
the same time maintaining sleep hygiene is also very important and it will certainly
help you in recovering from your problem. I would like you to maintain a sleep diary
for two weeks to see the sleep patterns. Please keep regular bedtimes and wake
times, even on weekends and days off from work. Limit or stop the use of nicotine,
caffeine and alcohol. Exercise regularly, but no later than late afternoon or early
evening. Do not use the bed as a place to worry especially about not sleeping. If you
feel necessary, write down all your worries and concerns before you go to bed and
place the list on your dresser to examine the next morning. Use the bedroom only
for sleep. Don't read, watch television, eat or do other activities in bed. Try to avoid
daytime naps. But if you must nap, do so in the early afternoon and for no longer
than 30 minutes per day. Eat a light snack (but not a heavy meal) before bedtime if
food is needed because of hunger. Get regular exposure to outdoor sunlight,
especially in the late afternoon." If you follow all these you may no longer have
problem with sleep. We usually don't recommend medications as this problem often
resolves with these behavioral modifications. Ok

Do you have any questions?

Explanation about insomnia:

Certain medical conditions, such as COPD, GERD, peptic ulcer disease, BPH
(resulting in overflow incontinence) and congestive heart failure with associated
paroxysmal nocturnal dyspnea, frequently disturb sleep and may be interpreted by
the patient as insomnia.

37

Patients with chronic pain, such as that resulting from chronic pain syndromes,
fibromyalgia, cancer pain may have insomnia and early-morning awakening. They (SP)
wont tell unless you ask specifically about the pain.

A psychiatric disorder, such as depression, is frequently a cause of chronic

insomnia, especially in the elderly.

Periodic leg movements during sleep are common in persons over 65 years of age.
Although these limb movements are often associated with brief arousals, many
patients have no sleep symptoms.

Regardless of the cause of insomnia, most patients benefit from behavioral

approaches that focus on good sleep habits. Exposure to bright light at appropriate
times can help realign the circadian rhythm in patients whose sleep-wake cycle has
shifted to undesirable times.

Chronic insomnia may reflect a disturbance in the normal circadian sleep-wake

rhythm as in this patient.

38

A 65 yr old lady with Dizziness:

Not only in CSA exam, even in real life dizziness is both challenging and frustrating for the
clinician. Dizziness is a nonspecific term. Vertigo, non-specific "dizziness", disequilibrium,
presyncope or near syncope can all be complained as a simple word "Dizziness" by the
patients. Obtaining an extensive history is most important to put the patient into one of
these more specific categories.
Encounter with the SP:

"What brought you in today?" (I feel dizzy)

"Can you please explain me little bit more about your dizziness?" (I always feel
dizzy, I don't know what you want me to explain)

Make a good eye contact and say, "Well..., It looks like you are not in a good
mood. I am here to help you. Are you comfortable madam? Is there anyway that I
can help you?" (My mood is ok just help me from this dizziness)

"Ok, I do understand that most people with dizziness are not happy. But I want
you to help you. To clearly understand your problem I need to ask few questions very
quickly is that Ok with you?" Note that she wont be happy all the time during this
encounter. She could be an uncooperative Patient

"Tell me what do you mean by dizzy?" (Dizzy means dizzy)

"Well, Many people describe their problems as dizzy though its not real
dizziness. Anyway when you get dizzy do you feel like room is spinning around you?"
(No) or "do you think that you are spinning inside?" (Yah)

"Is your dizziness constant at all the time or does it just comes and goes"
(Comes and goes)

"When did dizziness first occur?" (2 weeks ago), "How often do you get?" (Once
or twice in a day), "How long do they last?" (1 to 5 minutes)

"Do you have any warning signs that the attack is about to start?" (No not
really), "Do they occur at any particular time of the day or night?" (I am not sure).

"Does change of motion make you dizzy?" (I don't know)

"Do you know of any possible cause of your dizziness?" (I don't know)

"Do you know anything that will stop your dizziness or make it better?" (No)

"Do you know anything that will make your dizziness worse?" (No)

39

"When you get dizzy do you have a tendency to fall?" (Yes) "To which side? Is it
to right? Or Left?" (I don't remember)

"Have you ever lost consciousness?" (No)

"Do you have loss of balance when walking?" (Yah sometimes)

"Have you had any headache when you get dizzy?" (yah light headedness) "Do
you have it now?" (No), "Have you had any vomitings when you get dizzy?" (No),
"Have you had any palpitations or shortness of breath or a feeling of panic when you
get dizzy?" (No)

"Have you noticed any difficulty in hearing?" (No).

"Do you hear any ringing in the ears?" (No)

"Do you have any problems like double vision or blurry vision?" (No)

"Have you ever noticed any weakness in the arms or legs?" (No)

"Do you have any numbness on face or arms or legs?" (No)

"Do you have any other medical problems other than dizziness?" (I have low
blood pressure), "Have you had any heart problems?" (No)

"Have you ever been hospitalized?" (Yes for stroke few years ago)

"Have you ever had history of trauma to your head or neck?" (No)

"Are you allergic to anything?" (No)

"Are you taking any prescription medications now?" (Yes aspirin), "Any over the
counter medications?" (No)

"Do you smoke?" (no), "Do you take alcohol?" (Yah social drinking, 1 to 2 beers in
the weekend)

"Do you have any problems with your bowel movements?" (No)

"How is your bladder function?" (Good)

"How has your appetite been lately?" (Good)

Ask about family health.

Examination:

Do complete quick CNS exam, which must include nystagmus, gait, Romberg's
test, and cerebellar function tests.
Note: Not only in the CSA exam people with dizziness are often reluctant to
move because of the fear of fall, though they are able to walk. Before you

40

test gait or Romberg's test you have to say "I can imagine how
uncomfortable it is, but I am here to assist you, I will help you in every
aspect of the examination. This wont take more than a couple of minutes."

Auscultate for "carotid bruit"

Auscultate heart

Hearing tests - If you get a positive history of hearing loss

Do otoscopic examination if you get any positive history like ear discharge, pain
in the ears, ringing in the ears and aural fullness.

As long as memory is intact you don't need to do MMSE and obviously you don't
get time. So always do most important things first.

Differential diagnosis in general for dizziness case:

Benign positional vertigo

TIA

Stroke

Postural hypotension/Orthostatic hypotension

Arrhythmias

CNS tumors Meniere's disease

Drug induced/Polypharmacy

Nonspecific dizziness

Peripheral neuropathy

Thyroid abnormalities

Anemia

Metabolic disturbances like hypoglycemia

Investigations:

Check orthostatic hypotension

CBC with differential

Basic metabolic profile (Na, K, Cl, CO2, BUN, Cr, Calcium and blood sugar).

Thyroid function tests

Carotid Doppler - If you get a relevant history for stroke/TIA

MRI of brain - For suspected acoustic neuroma or any CNS tumor

24 hr Holter monitoring - In patients with H/O palpitations and cardiac disease

41

Note: If you get an uncooperative patient it is very difficult to get everything in 15 min as
they don't cooperate and don't do all the tests properly. So don't get panic, try to do as
much as you can and remember that they are told to act like that. This problem is for all
the CSA takers. So again the key to pas this exam is practice, practice and practice.
Short explanation about dizziness:
Vertigo: Unless it is a mildest form, it is usually associated with nausea, vomiting, and
perspiration, indicating excessive autonomic activity. Typically there is no loss of
consciousness. Because the only objective sign of vertigo is nystagmus, examination of eyes
is extremely important and they expect you to check the eyes. You have to tell the patient
that you are checking the eyes. If you just examine without informing you don't get point
for that.
Presyncope: Its a perception that he or she is about to faint. Patients may have associated
symptoms like constriction of the visual fields, diaphoresis, and nausea but there is no
actual loss of consciousness.
Disequilibrium: These patients typically do not have problems when sitting or lying down but
notice unsteadiness when standing or especially during walking. These patients also do not
loose consciousness.

42

Heel pain (Or) Foot pain:

Ask about the location of pain

Ask about the intensity of pain

Ask about the quality of pain

Ask about the origin and duration of pain

Ask about the radiation of pain

Ask about the aggravating factors in detail ( walking, standing, "After standing, how
long does it take for the pain to start?" etc.)

Ask about the alleviating factors

Ask about the prior episodes and frequency

Ask about any trauma to foot

Ask about the associated factors like fever, and other joint pains

Ask about the morning stiffness

Ask about the prior H/O diarrhea or any acute illness (For possible reactive
arthritis)

Ask about the urethral discharge and conjunctivitis ( For possible Reiter's
syndrome)

Ask about the H/O rash (For psoriatic arthritis)

Ask about the occupation and type of work in detail ("What type of work do you do?
Does your work involve any prolonged standing? Do you have to walk a lot at you
work?")

Ask about the family H/O rheumatoid arthritis or any other joint diseases

Ask about any other medical problems

Ask about medications

Ask about allergies

Ask about sexual history

Ask about social history

Examination:

Inspection of the foot (Let the SP know that you are inspecting).

Palpation of the entire foot (not just the heel) for any point tenderness.

43

Check for the range of motion at the ankle & forefoot joints. Note the pain &
restriction of movements.

Ask the patient to do active dorsiflexion and plantar flexion and see for any tendon
tenderness (For tendinitis).

Check the eyes for possible conjunctivitis (If you suspect Reiter's syndrome).

Investigations:

CBC with diff

X-ray of foot and ankle 3 views

Rheumatoid factor assay

Differential diagnosis:

Plantar fasciitis

Calcaneal periostitis

Calcaneal spurs

Painful heel pad syndrome

Bone tumors

Rheumatoid arthritis

Reiter's syndrome

Counseling:

After the appropriate closing you can counsel like this "I have to order X ray of
foot, ankle and some basic blood tests before we come to a proper diagnosis. Mean
while I will try to help you to relive your pain. Give 2-3 days of rest to your foot,
apply icing for 30 minutes for every 4hours, and use soft heel pads. At the same
time take over the counter ibuprofen 400 mg 3 times a day. You can also try resting
padded foot splint; these splints are available in pharmacies that feature orthopedic
supplies. Wearing slippers or going barefoot may result in a recurrence of your
symptoms. So your first step out of bed should be made with a supportive shoe or
sandal on. You have to avoid excessive heel impact from jumping, walking. Most of
the times people will get better with these measures. If you don't getter better or
if your tests shows abnormal results we will sit together and will discuss the other
possible options." Is that ok with you? (Sounds great Doc)

Good thank you. Do you have any other questions?

44

Short explanation:

Disorders of the ankle and foot, including ankle sprains, tendinitis, plantar fasciitis,
and bursitis usually occur in association with movement and result from trauma.

The common underlying problems include osteoporosis, spondyloarthritis and

enthesitis (inflammation at muscle insertions) of lower limb structures, improper
footwear, moving from a home with wood flooring to one with a slab foundation,
prolonged standing on concrete floors, and structural disorders such as joint laxity
or malalignment of the lower limbs.

Plantar fasciitis:

Plantar fasciitis is one of the most common causes of foot pain in adults. Heel spurs
often coexist and may represent a secondary response to an inflammatory reaction.
The predominant symptom of plantar fasciitis is pain in the plantar region of the
foot that is worse when initiating walking. A hallmark for diagnosis of plantar
fasciitis is local point tenderness. This is best elicited by the examiner dorsiflexing
the patient's toes with one hand in order to pull the plantar fascia taut, and then
palpating with the thumb or index finger of the other hand along the fascia from
the heel to the forefoot.

In addition to soft tissue pain or fasciitis, plantar heel pain may be induced by a
number of other disorders. These include nerve pain due to entrapment, bone pain,
tendinitis of the posterior tibia or flexor digitorum longus tendons, or the presence
of tumor or infection. Reiter's syndrome and other spondyloarthropathies,
Lofgren's syndrome, and sarcoidosis should also be considered in the differential
diagnosis.

Radiographic studies are usually recommended in patients with persistent plantar

pain after a trial of conservative therapy. Lateral and axial radiographs are the
appropriate views due to the myriad of diagnostic possibilities. The primary goal of
radiography is to rule out other disorders.

The soft tissue may be evaluated with MR imaging in cases that are resistant to
treatment. Technetium scintigraphy has also been successful in localizing the
inflammatory focus and ruling out stress fracture.

Calcaneal periostitis

45

Calcaneal periostitis may result from trauma, Reiter's syndrome, ankylosing

spondylitis, psoriatic arthritis, or rheumatoid arthritis. Pain is usually bilateral, along
the lateral and plantar aspect of the heels, worse in the morning upon arising, and
often accompanied by morning stiffness. Tenderness is diffusely present along the
plantar aspect of the heel and midfoot, and along the lateral border of the heels.

Bilateral involvement should alert to the possibility of a coexistent systemic

rheumatic disease.

Calcaneal spurs

Calcaneal spurs can develop on the plantar tuberosity and extend across the entire
width of the calcaneus.

Heel spurs are typically asymptomatic; pain occurs when the apex is angled
downward by depression of the long arch. An acutely painful heel spur may also be
seen in certain systemic diseases, such as ankylosing spondylitis, Reiter's syndrome,
or rheumatoid arthritis.

Painful heel pad syndrome

The painful heel pad syndrome most often occurs in marathon runners. It is thought
to result from disruption of the fibrous septae that compartmentalize the fat in the
heel pad. Pain is localized to the heel pad; the plantar fascia is not tender and pain is
not accentuated as the examiner dorsiflexes the toes.

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Low back pain:

If you get a case of low back pain consider these things:

Ankylosing spondylitis

Herniated lumbar disc

Spinal stenosis

Osteoporosis with vertebral crush fractures

Metastatic bone cancers

Primary bone tumors like multiple myeloma

Rheumatoid arthritis

Examination:

Check spinal tenderness

Check paraspinal tenderness

Check lower extremity pulses

Check sensations of the both lower extremities

Do complete motor and reflex testing of the both lower extremities

Do straight leg raising test

Check lumbosacral spine range of motion

Check the gait

Investigations:

CBC with diff, ESR

HLA-B27

Rheumatoid factor levels

X-ray of the lumbosacral spine

MRI of the spine

Upper extremity pain:

If you get a case of upper extremity pain consider these issues:

Carpal tunnel syndrome (ask about the occupation)

Cervical spondylitis

Herniated cervical disc

Thoracic outlet syndrome (ask whether the symptoms worsen with the above head
activities like combing)

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Tenosynovitis

Trauma

Referred pain from coronary ischemia

In the history just follow LIQOR AAA and PAM HUGS FOSS.
Examination:

Check the thyroid gland

Check the neck movements and the range of motion

Do thoracic outlet test ( Adson's test) - Ask him to take the deep breath, extend
the neck and turn the chin towards the opposite side and repeat the test with the
chin opposite side. In the presence of thoracic outlet syndrome the radial pulse will
disappear.

Do Phalen's test (for carpal tunnel syndrome) - Hold the patients wrists in acute
flexion for 30- 60 seconds. Patient will complain of pain, numbness and tingling over
the distribution of medial nerve if the test is positive.

You can also elicit Tinel's sign also if you want. With your finger percuss over the
course of medial nerve in the carpal tunnel. Patient will complain of pain, numbness
and tingling over the distribution of medial nerve if the test is positive.

Check sensations, do motor and check reflexes of the upper extremities both sides.

Investigations:

CBC with differential, ESR

EMG and nerve conduction studies

X-ray of the cervical and thoracic spine

EKG

MRI of the spine

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A 25 yr old female with nausea and vomiting

First think about the common causes of nausea and vomiting in this age group

Gastroenteritis (food poisoning) - Ask about having food out side / travel history/
any other members being ill/ associated symptoms like abdominal cramps and
diarrhea

Obstructing disorders - pyloric obstruction (classically vomiting within 1 hr after

having food), intestinal obstruction (vomiting late post prandial period)/
constipation/ is she passing gas (don't ask flatus; if you ask flatus SP will say 'what
is that?'*). Relief of the pain with emesis is very characteristic of small bowel
obstruction. Vomiting has no effect on acute pancreatitis or cholecystitis.

Inflammatory diseases (cholecystitis - pain in the right hypochondriac region, acute

pancreatitis - severe epigastric pain radiating to back, appendicitis - initially
periumbilical pain later to right lower quadrant pain)

Impaired motor function - Diabetic gastro paresis, GERD ( So ask about any history
of diabetes may be type I in this female)

Intracebral disorders like malignancy, infections - So ask about fever, headache and
the quality of vomiting (projectile or not).

Drugs (diogxin, cancer chemotherapy) - Just ask are you taking any medications.

The 2 most common conditions and you will be likely to be tested in the CSA are
pregnancy and anorexia nervosa. You should not forget to ask about the LMP
because if you get a case of nausea and vomiting in the CSA it is most likely a
pregnancy and in fact the SP may ask you "Doc is it a pregnancy?"

Always follow the PAM HUGS FOSS because post operative vomiting, ethanol intake,
drugs, diabetes, OBGYN history (LMP) will cover automatically and you don't need to
remember what to ask.

Don't worry about the rare causes (labyrnthitis, uremia, adrenal insufficiency) of
vomiting for this exam.

Please follow the history taking section of the site for complete description of vomiting.
Examination:

Auscultation of the abdomen (decreased bowel sounds indicates ileus, increased

bowel sounds indicates bowel obstruction)

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Abdominal palpation both superficial and deep

Fundoscopy if you are suspecting intracranial causes

Explain about the need of rectal examination and pelvic examination (pregnancy)

Quick lungs and heart exam

Finally if you have some time look at the oropharynx

Investigations:

CBC with diff

Pregnancy test (must for this female)

FOBT

Serum amylase and lipase (if you are suspecting) acute pancreatitis

Ultrasonogram (acute cholecystitis)

Blood sugar for DM

EKG should be obtained if patient has risk factors for MI (some times inferior wall
MI presents only with vomitings especially in diabetics) but do not order for this
female unless patient has intractable vomitings and you are worried about
hypokalemia.

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A 34 Yr O/F came for Bronchial asthma drug refill

This case is not that much important but always there is a possibility, so just have a
look

The things that you need to ask specifically for this case are

Start with formal greeting, ask open ended question like "What brought you in
today?"

"Can you please tell me more about your asthma?" Like "When were you diagnosed
for the first time?" and "How have you been doing since then?"

"Can you please tell me about your current medications?" or " What medications are
you on?"

"Did you notice any problems or side effects with your medications?"

"Do you have any trouble breathing during the day or night with regular activity?"
(yes)

"How often does this occur on a weekly basis?"

"Do you have any trouble breathing with exercise?" (yes)

"How often does this occur on a weekly basis?"

"Do you have episodes of excessive coughing during the day or night time?" (yes)

"How often does this occur on a weekly basis?"

"Have you ever been admitted in the hospital for an acute or severe attack?"

"Tell me what do you think about the severity of your asthma ? Do you think is it
getting better or worse? Do you know what precipitates your asthma?"

"Are you taking any precautions to avoid those?"

After this you will just have to follow PAM HUGS FOSS. Make sure you ask smoking history
and tell about the importance of smoking cessation.
Examination basically requires HEENT to look for any sinus tenderness (sinusitis), signs of
upper respiratory tract infection, which can aggravate or precipitate asthma. You have to do
complete lung examination. Look for JVD and pedal edema for signs of cor pulmonale even
though it's a very rare complication of asthma.
Spirometry or pulmonary function tests are usually not required unless the patient is elderly
and having persistent asthma. CBC with differential, Aspergillus serology, Chest X ray, X-

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ray of Para nasal sinuses, 24 hr pH for GERD and skin tests are required in chronic
persistent and refractory asthma.
Differential diagnosis for chronic persistent asthma in a smoker includes
1.

Bronchial asthma

2. COPD
3. Broncho pulmonary aspergillosis
4. Sinusitis
5. Atypical GERD

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