Complete USMLE CS Guide Notes& - 40 1& - 41 & - 40 1& - 41

USMLE STEP 2 Clinical
Skills Basic CS Notes

Authors: Majid T. Aized & XAK
Revised & Edited by: R. Khalid & M. Shoaib
Approach to USMLE Step 2CS Cases
USMLE CS has two parts
 Encounter: It is what you want to do with the standardized patient (SP). You should not use medical
terminology during this. The main goal is to finish your checklist ticks! It has 5 parts. Each part has its
respective weightage.
o Opening (6 Points)
o History = OFDP(LIQR)AAA + DDs (Variable)
o General Question = PAMHUGSFOSSS (6-8 Points)
o Physical Examination (Variable Points)
o Closure (6 Points)
 Patients Notes: There are 3 major portions and 2 minor portions of the notes by weightage.
o Major = HOPI with denials + DDs with bullet points + Labs
o Minor = Rest of HOPI + Physical Examination
(NOTE: Any significant physical finding gets more weightage so do not forget to write it down)
RedFlags
Red Flagsof
ofCS:
CS:
 Assoon
As soonasastime
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ends,you
youLEAVE
leave the
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ROOM.
 Do not
Don’t bebe disrespectfulwith
DISREPCTFUL withthethePROCTORS.
proctors.
 Do not
Don’t share/discuss your
SHARE/DISCUSS your cases
CASEsonline.
ONLINE.
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At Doorway:
Note the following things:
1. Age (if >50 years, write PMDC)
2. Name of Patient (Last name with Mr. for male and Miss for Female)
3. Chief Compliant
4. Vitals (write only if some finding is abnormal like high BP or fever etc.)
Encounter
You must get 25 to 30 ticks checked from the list. They are divided into five portions. Say the patient's name
at the start of each portion. Use normal speed for opening, transitional sentences for general questions,
commands for physical exam and closure. For the rest, be swift and fast.
OPENING
Six points of Opening
1. Greeting (Hello/Hi, Mr./Miss. XYZ + Good morning/evening)

2. Introduction (Last name with your designation + what you are going to do with him/her)
3. Comfortability
4. Permission for note writing
5. Open-ended Question
6. Rephrase
(NOTE:
(NOTE:InInER
ERcases,
cases,comfortability
comfortabilityprecedes
precedesthe
theintroduction
introductionand
andgreetings
greetingsare
areusually
usuallyskipped)
skipped)
Knock Knock. (Don’t say patients name outside the room because it will go against HIPAA’s confidentiality
guidelines. Wait for the patient’s response. (Red flags: Don’t barge into the room)
When you enter the room, remember to SMILE  Remember to pause throughout your intro and be
slow (it’ll make the patient feel comfortable).
You: Mr./Miss XYZ?

SP: Yes.
You: Hi, my name is Dr. ABC and I am your physician here today and I will be asking you some questions
regarding your health followed by a brief physical examination. Is that OK with you?
SP: Yes, sure.
You: Thank you for allowing me to do that. It seems that you are nicely draped, is there anything I can do to
make you more comfortable?
SP: No, that’s fine.
You: Okay, alright. I hope you don’t mind if I take my notes while talking to you.
SP: Sure.
You: So, how can I help you Mr./Miss XYZ?
SP: Dr, I am having _________ problem.
You: Oh, I am so sorry to hear that, but let me assure you that I am here to help you as much as I can and
you do not need to worry. You are in safe hands. So, can you please tell me more about it?
(Note: If the patient gives you a vague complaint like not feeling well, feeling dizzy or winding then before
asking details question, first ask what do you mean by that/complaint? Then, ask about the details)
SP: SP will tell you a story in more than 80% of cases with giving details about the 1st differential. Listen
carefully to the story while the patient finishes and do not interrupt.
You: Thank you so much for sharing this valuable information with me. Let me rephrase what you have told
me so far? Repeat the patient’s story. After repeating, ask the patient: Is this correct?
SP: Yes etc.
You: Alright, let me make a note of it.
After writing down important information:
You: I want to ask more questions so that I can have the better idea what’s going on wrong with you?
HISTORY
OFDP(LIQR)AAA
OFDP(LIQR)AAA+ DDs
+ DDs
Most of the OFDPAAA will be told by the patient already, so ask the rest of questions out of OFDPAAA.
OFDPAAA is used almost in each and every case (with little variability in some cases). In cases of pain, use
OPDPLIQRAA. Use signs that are shown rather than using the whole word. It will save more time with
maximum eye contact with the patient.
O: How did this start? S-sudden, G-gradual

F: Is it Continuous (C) or Episodic (E)?
(If episodic then ask: have you experienced similar episodes in the past? What is the duration of each
episode? When was the last episode?)
D: For how long have you are having this problem? (D-days, m-minutes, M-months)
P: Since it started has it been the same or getting worse? (↑=Progressive, →=Non-Progressive, ↓= Getting
better)
(In cases of episodes, progression is either increased in duration or increased in frequency of episodes. So
ask, if there any difference between this episode and previous episodes)
L: Can you exactly locate your pain?
I: On scale 1-10, how will you grade your pain; with 1 being the minimum and 10 being the maximum?
Q: Can you please describe the quality of your pain?
R: Does this pain go anywhere else?
A/↓: Anything making it better?
A/↑: Or worse?
A: Anything associated with it? If yes, ask details too (Atleast OFDP)
(In MSK-musculoskeletal cases, associated features are WRSS WNT

Warmth + Redness + Swelling + Stiffness + Weakness + Numbness + Tingling)
After that, move to your DDs portion and first ask most probable differentials to rule in DDs based on
OFDPAA. Then, ask the rest of DDs to rule out other differentials as well.
DD1  In ER cases, on entering when patient is in immediate distress, say:

DD2 Mr./Miss XYZ, it seems that you are in much discomfort. Is there anything I can do to
DD3 make you more comfortable? (After that say/add) Let me assure you that I am here to
help you. (Like switching off lights in case of SAH)
DD4
DD5  If patient’s name is difficult, ask from him/her in beginning that am I pronouncing
DD6 your name correctly?
DD7
DD8  If patient is coughing, offer a napkin and a glass of water (NOT IN CASE OF BELLY
PAIN). If patient takes napkin or holding one already, (at the end of encounter say) you
need it to get phlegm examined.
PAMHUGSFOSSS
PAMHUGSFOSSS is divided into six parts.
1. Past Medical Health = Any Chronic Illness + Allergy + Medication + Hospitalization

2. General Health/Review of System (ROS)
3. Family Health
4. Gynecological Health
5. Social/Sexual Health = SODA = Smoking + Occupation + Drug Abuse + Alcoholism
6. Screening Question and Summary = PMDC = PAP + Mammography + DEXA + Colonoscopy
Before starting each part, use the transitional sentences. Transitional sentences should be in normal tone.
1.1.Past
PastMedical
MedicalHealth
Health:
So, Ms. XYZ now I’m going to ask you a few questions about your past medical health. Is that okay?
1. Have you experienced any similar complaints in the past?

(Note: In case of episodes, this question is usually asked in the OFDPAAA part)
2. Are you suffering from any diagnosed medical illness? (If SP replies NO, then give the leading question)
like any high blood pressure (BP) or high blood sugar (BS)? Now, if SP says NO, now it’s negative.
(Note: Do not say Hypertension or Diabetes, although SPs know but still it’s better to avoid)
If Answer is yes, then ask following questions.

 For how long have you had this problem?
 Are you taking any medication (M) for that? + = Yes
-- = No
 Are you compliant (C) with your medication?
+/- = Occasional
 Do you visit your Doctor (Dr) regularly?
 When was your last visit?
 What was the last reading?
If the patient has a complaint for which he/she are compliant with the doctor's advice and it's well
controlled, then appreciate the SP like “Well Mr. XYZ it seems that you are taking very good care of your
health so please keep it up.”
If the patient is non-compliant or disease is not well controlled then advise the SP like “As your Dr., let me
inform you that uncontrolled BP ± BS can cause several illnesses especially diseases of hearts and lungs
including some cancers too. So as your concerned physician I advise you to control your BP ± BS, visit your
primary care doctor regularly, and be consistent with your medications.”
(Note: If patient has both DM and HTN you can appreciate or counsel synchronously – in the same
sentence to save time)
3. Are you allergic to anything?
If SP says NO, then say like any foods or medications?

If SP says YES, then ask what happens when you have it?
 If they are allergic to food, say: Please keep 2 epi-pens with you always in the case of an emergency.
(Shrimp allergy: say “Well I’ll make a note of that and I advise you to continue avoiding seafood restaurants
in case your food is cross-contaminated with shrimp and you have an emergency.”)
 If it is medicine allergy, say: This is vital information for me and I am making a note of it so that you
don’t receive this drug in the future.
4. Have you had any hospitalizations in the (recent) past? Yes/No.
2.2.Review
ReviewofofSystem:
System:
Now a few questions about your general health, is that all right?
Have you noticed any changes in your sleep recently? Any urinary habits change? Any bowel movement
changes? Any Nausea/vomiting? Any fever recently? Any weight change recently?
Ask the first question completely with word ‘recently’. Rest of ROS can be asked by just with ANY. If
something is positive/significant, then ask the question: Can you please tell me more about it? You just need
to ask OFDP – onset, duration, frequency, and progression of associated/ROS complaints.
For Joint pain (especially knee pain), add CITRUS = Conjunctivitis + Insect Bite + Travel/Trauma Hx + Rash +
Ulcer in mouth/urinary discharge + Stiffness/sore throat
3.3.Family
FamilyMedical
MedicalHealth
Health:
Now, I would like to ask you about your family health, is that okay?
Are your parents alive? If Yes then ask, how is their health?
 Alive and Healthy: Nice to hear that and please pay my regards to them.
 Alive
So is there anyand Healthy:
disease thatNice
runstoin hear that and
the family? please pay my regards to them.
Yes/No.
So is there
Aliveany
but disease that
diseased: Oh,runs
I’min
sothe family?
sorry Yes/No.
to hear that. Are they taking medication for that?
 Deceased: Oh, I’m so sorry to hear that. Please accept my deep condolences. So, sorry ask how
they passed away? Relevant/Irrelevant.
4. Gynecological
If irrelevant then nexthealth:
question is, so is any there any disease that runs in your family?
5.Ob/Gyn
4. Ob/GynHealth
Health:
So, Miss XYZ is it all right if I ask you a few questions about your gynecological health?
If it is the Non-Gynecological case, then ask the following question?

 When was your last and first menstrual period?
 What is the length of cycle? With how many days of bleed?
 Are your cycles regular? If cycles are irregular, how many pads/day are used?
 When was your last Pap smear? And what was the result?
If the case is Gynecological, then ask LMP RT CVS PAP after OFDPAA and before starting DDs. Use
transitional sentence there, as well.
 L: When was your last menstrual period?

 M: When was your first menstrual period?
 P: Any pain during menses/intercourse/defecation?
 R: Are your cycles regular?
 T: How many tampons do you use on a heavy day?
 C: Any crampy pains during menses/intercourse?
 V: Any vaginal discharge?
 S: Any spotting?
 PAP: When was your last Pap smear? And what was the result?
5. Socialand
5.Social andSexual
SexualHealth/Habits:
Health/Habits:
So, Mr./Mrs. XYZ, I am going to ask you a few questions about your social and sexual heath and
everything you will tell me will be kept completely confidential, is that alright with you?
1. Are you sexually active? Yes, with whom, may I know? For how long you are in this relationship? Are you
using any contraception methods/measures? Yes/ No
If you are suspecting some STI or there are some risk factors for STI, then ask: Have you ever been tested for
STIs especially HIV? (If they say NO, then say) As you have risk factors for STIs I would encourage you to
undergo screening for STIs. Should I enroll you for that? Yes/No
 If the patient is homosexual whatsoever the duration of the relationship is, you must ask for
 If the patient is homosexual whatsoever the duration of the relationship is, you must ask for
contraception usage.
contraception usage.
 If the patient is heterosexual but the relationship is < 6-12 months, ask for contraception.
 If the patient is heterosexual but the relationship is < 6-12 months, ask for contraception.
 If the patient is heterosexual but the relationship is > 12 months, no need to ask for contraception.
 If the patient is heterosexual but the relationship is > 12 months, no need to ask for contraception.
Ask only in this case, if you are suspecting some STIs – sexual transmitted infections.
Ask only in this case, if you are suspecting some STIs – sexual transmitted infections.
If the patient is using contraception regularly, appreciate him/her like “it seems that you are taking very
good care of your health, please keep it up”.
If the patient is not using contraceptives regularly then counsel him/her. “As your physician let me inform
you that failing to use contraception does not only lead to the spread of sexually transmitted infections but
also unwanted pregnancies. So as your concerned physician, I would advise you to use condoms regularly”.
Now, few questions about your social health/habits (SODA), Mr./Miss XYZ.
 Do you smoke? If yes, for how long you have been smoking? How much do you smoke in each day?
 Do you drink? If yes, for how long you are drinking? How many glasses in each day?
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E: Do you need a glass of drink as an eye-opener?
 Do you use any illicit drugs? If yes, then ask which drug do you use? For how long you are using it? By
which route do you take it? When was the last dose/shot?
Smoking and Illicit drug use: Need counseling regardless of amount and/or duration.
Alcohol: Needs counseling only when male consume >2 drinks/day and/or >1 drink/day for the female and/or
binge drinking (>5-6 glasses/day for male and >4-5 glasses/day for female).
1.Triple Negatives:
1. Triple If patient
Negatives: denies
If patient all three
denies (triple
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say:say:
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3. Double positives: First
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6.6.Screening
ScreeningTests
Tests:
Don’t forget to ask about these questions in specific scenarios.
 Women >16-21 Years: When was your last Pap smear and what was the result?
 Women >40 Years: Have you ever undergone mammogram? What was the result?
 Women and Men >50 Years: Have you ever undergone colonoscopy? What was the result?
 Women and Men >65 Years: Have you ever undergone DEXA scan? What was the result?
Summary
So let me summarize what you have told me so far that you are having _______________. Do you want to
add anything?
(Note: During summary, tell the bullet points of your differentials you are thinking from OFDPAA, Differential
part, and PAMHUGSFOSSS part. Just tell the bullet points. Do not just rephrase OFDPAA here).
Thank you very much for your cooperation. Now let me sanitize my hands to do the physical exam.
(While sanitizing your hand ask) By the way, what do you do for your living? Then go to physical exam
according to your differentials.
Closure
Say it in simple language. It is the most important part of the encounter. Never miss it. It has following
parts:
 Empathy
 Diagnostic impression in simple language
 Labs: At least one from blood workup and one from imaging studies.
 Short term management: What you are going to do right now/in hospital settings?
 Long-term management: What are you recommending for the future/outside of hospital setting? It
comprises of
1. Case-based management: Specific to the case like regarding dementia, dizziness, abuse.
2. Addressing risk factors again: If the patient has risk factor in PAMHUGSFOSSS, shortly re-address.
3. General management: If none above present, then say “Do regular exercise, eat a healthy and
balanced diet full of vegetables and fruits and less in fats and/or salt.
 Questions and concerns
Well Mr./Miss XYZ, thank you for cooperation and I apologize for causing you any inconvenience. Depending
on the history and physical examination, I am thinking a number of possibilities for your current complaint. It
could be due to this or that. But I am not sure right now; to be sure about it, I have to run some tests
including some blood work up like a Complete Blood Count (CBC) and some imaging studies like X-ray and CT
scan if needed. When the results will be available, we will sit together and discuss the further management
plan and you do not need to worry as you are in safe hands and whatever the results are, we will deal this
together. Meanwhile, I am keeping you under observation and my nurse is going to give you some pain
medications etc. Moreover, I would advise you to quit your smoking/cut down your alcohol/eat a healthy
diet low in salt and more fruits and vegetables.
Do you have any questions/concerns for me? Yes/ No.
Well thank you, we will meet again when the lab results are available until then goodbye. Take care.
Notes
You can/should use medical terms here. Areas with the order of decreasing weightage are as following:
1. HPI = OFDP(LIQR)AAA + DDs Positives and denials

2. DDs with bullet Points
3. Labs
4. Physical Examination (if significant)
5. Rest of HPI = PAMHUGSFOSSS
For writing labs,

Line 1: Write down physical exams which cannot be performed like Fundoscopy, orthostatic vitals, rectal and
pelvic examination, gait examination, otoscopy, and breast examination.
Line 2: Rule in investigation for DD1
Line 3: Rule in investigation for DD2
Line 4: Rule out investigation for rest of differential (should be non-invasive)
Line 5: Baseline investigation (CBC w/ diff, UA, S/E, BUN, Cr etc.)
Posture
How should be your posture in the encounter?
 When you shake the patient’s hand, remove pencil out of your hand.
 Stand up straight, shoulders rolled back, and 3 feet from the patient.
 The feet must be broadly placed and there should be no shaking in the body language.
 Stand still and firm.
 Place your clipboard to the side, while closing the case.
 While leaving the room, you can say:
o Enjoy the rest of your day.

o Good night.
o Good day.
o Have a good day (in case of morning cases before the 12)
o See you soon
Physical Examinations
 Begin by standing directly in front of the patient or on the right side at approximately 3 feet distance.
 Maintain direct eye contact and start with a smile.
 First tell the patient what you are going to do, then perform the examination and then share finding
with the patient. (Auscultate before palpation in case of belly or CVS exam)
 Use warm hands. Rub your hands together before touching the patient.
 The drape is your property and gown is patient’s property. Do not move patient’s gown. Ask the
patient to move it for you while keeping his/her modesty while you can move drape as you like.
 Do not speak in front or close to the patient’s face or while doing an examination. Command him/her at
a distance.
 After giving commands, demonstrate to the patients.
Following are the different commands for the examination:
General Physical
Hands
 Mr./Miss XYZ, I am going to perform a general physical exam on you, is that alright?
 First I am going to inspect your hands for any sweating, pallor, or clubbing, is that fine?
 Please show me your hands like this (demonstrate for the patient and DO NOT speak your findings while
inspection)
 (After inspection say) Your hands seem perfectly fine to me.
Eyes
 Now I will be looking at your eyes for any pallor or discoloration. Can you please move your eyes up and
down for me like this (demonstrate to the patient)
 Your eyes seem perfectly fine to me.
Mouth
 Mr./Miss XYZ, I’d like to examine your mouth now so can you please open your mouth? (Shine light into
oral cavity) Can you please say “Ahhhh” for me? Alright, great everything seems fine to me.
Neck/Thyroid/Nodes
 I will be feeling your neck for any swelling or mass now. (Palpate thyroid and lymph nodes). Can you
please swallow for me? Great, thanks, everything seems fine to me.
Legs/Feet
 Alright, now I’d like to proceed to inspect your feet and legs for any swellings. Is that okay? (check his
legs/feet) Mr./Miss XYZ, they seem perfectly fine to me and that is very reassuring.
Pulses
 Lastly, I would like to examine your pulses first in the arms and then in the legs and compare the both.
(Palpate pulses) Okay, they seem fine and equal to me.
Thank you!
 Thank you for your patience and cooperation Mr./Miss XYZ, let me document all these vital findings! 
Central Nervous System Examination
Mr./Miss XYZ, I am going to examine your nervous system now and first I’ll start off by checking the nerves
coming out of your brain. Is that alright? Can you please remove your glasses? (if he has them on) If you feel
any discomfort or pain during the examination please let me know and I will stop right away.
Cranial Nerves
 Mr./Miss XYZ, please follow my finger without moving your head (draw an “H” in the air)
 Can you please close your eyelids and resist me opening them?
 Can you please frown for me? 
 Can you please give me a smile? 
 Can you please show me how you blow out candles?
 Can you please clench your teeth?
 Can you please shrug your shoulders? Alright, can you please shrug them against my hands? (Apply
resistance)
 I am going to perform a whisper test. I’ll be rubbing my fingers in front of your ears and then please let
me know if you hear the sound produced (rub fingers in front of both ears) Did you hear that? And was the
sound equally heard on both sides?
 Alright, can you please move your head sideways and up and down? And now can you repeat the same
movements, but against the resistance of my hand this time? (Apply resistance)
 Mr./Miss XYZ, I am going to check the sensation of your face. I’m going to touch you like this
(demonstrate how the touch) if you feel it please let me know. Close your eyes and perform: do you feel it?
(Perform on three places in each nerve distribution) Was it equal on both sides?
 Okay, can you please open your mouth and say “Ahhh” Can you please show me your tongue alright can
you move it up and down and to the right and left. Can you give me a quick swallow now? Thanks!
 Alright, Mr./Miss XYZ, the nerves coming out of your brain are fine and that’s very reassuring! 
Power
 Now I am going to proceed to examine the rest of your nervous system.
 I will check the power of your muscles.
 Can you assume this posture for me? Please resist my actions.
o Elbows --- extension and flexion
o Lower limb --- Can you kick in against my resistance? Can you kick out against my resistance?
o Ankle --- Can you push the gas pedal down against my resistance...and lift off the gas pedal against my
resistance.
 The power of the muscles in your limbs is fine Mr./Miss XYZ.
Sensory
 I’m going to check the sensation in your arms and legs now. I am going to touch you like this
(demonstrate to the patient). Can you please close your eyes and let me know when you feel it? Perform at two
places on upper limb and at two places in the lower limb. Do you feel it? Was it equal on both sides? Okay,
that’s very reassuring.
Reflexes
 Now I’m going to be checking your reflexes Mr./Miss XYZ. This is a rubber hammer made of rubber
which I will strike to check your reflexes and it will not hurt you. Can you please assume this posture (arm
flexed at the elbow against belly). Perform bicep and knee reflexes. Okay, Mr./Miss XYZ, your reflexes are fine
in both your upper and lower limbs.
Gait
 I will be examining your gait in the latter part of the day.
Thank you!
 Thank you for your cooperation and patience! Let me document all these vital findings.
Abdominal Examination
Mr./Miss XYZ, I’ll be examining your belly now is that alright? For this, I have to untie your gown. Let me help
you lie down. Let me pull out the foot rest for you. Mr./Miss XYZ, I’m holding the drape to ensure your comfort
so please adjust your gown up to your comfort level.
Inspection
 I am first looking at your belly first for any abnormalities, swelling, pulsations, striae, or scar marks.
Please rest your arms on the side of your body (if they are crossed over the belly). Okay, everything seems fine
to me!
Auscultation
 Now I’ll listen to your belly sounds with my stethoscope (do this in two to three areas). They seem
perfectly fine to me, very reassuring! 
Palpation
 Alright, now I’m going to be touching your belly to check for any pain or any swelling. If you feel any
pain or discomfort, let me know and I’ll stop right away. Can you please tell me where you feel pain? Okay, I’ll
be sure to be gentle (Palpate painful area at the end).
 If he experiences pain to say “Oh.I am so sorry Mr./Miss XYZ for causing you pain. This was a very vital
part of my examination and will help me make a final diagnosis for you.”
Percussion
 Okay, now I’m going to be tapping on your belly to check for any free air or fluid. Is that okay with you?
(Percuss) Thank you, Mr./Miss XYZ, it seems perfectly fine!
Help the Patient Sit Up
 Please lower your gown while I am holding the drapes. Let me help you to sit up. I’m pushing back the
footrest. Let me tie the knot your gown again.
Thank you!
 Mr./Miss XYZ, thank you very much for being patient and cooperative. I’ll be sure to record the vital
information I’ve gathered! 
CVA Tenderness
 I’ll be continuing to inspect your back (move to the back and look at the back) your back seems perfectly
fine to me.
 Now I must perform a maneuver called CVA tenderness. It is used to check for the swelling of the
covering of the kidneys. It may be slightly painful for you but let me assure you that if it comes positive, it will
be a very vital piece of information for me and will help me make a diagnosis. Is that okay?
 (Tap the right and left flanks and have one hand laid over areas.) Did you feel any pain? Oh, I am so
sorry you felt the pain, but this is very vital information for me.
CVS and Respiratory Examination
I am going to be examining your heart and lungs. Is that alright? Mr./Miss XYZ, I’m going to untie your gown
first. Please lower it to your comfort level.
Inspection
 I’m going to inspect the front and back of your chest for any abnormalities, pulsations, or visible veins is
that fine? (look in front, from sides, and back) Alright, the front and back of your chest seem fine to me.
Palpation
 Now I’ll be touching your chest to feel for any pain or deformities or swelling. If you feel any pain please
let me know and I’ll stop right there. Warm your hands then palpate in 4-6 quadrants. Did you feel any pain?
Ok, that’s great and reassuring. 
 I’ll feel for your heart now. Place right hand on apex and with left hand start from sternal notch and
count ribs downward to localize beat. It seems perfectly fine to me.
Auscultation…heart & carotid sounds + lung sounds

 Now I am going to listen to your heart and any neck sounds using my stethoscope. Auscultate in 4
cardiac areas and carotids with breath holding for each. Ok, both heart and neck sounds are fine.
 I’ll listen to your breath sounds next. Whenever I place the stethoscope on your chest please follow my
commands and hold your breath between breathing in and out. Alright please, breathe in, and hold and
breathe out (repeat this in 4 areas in front and 4 areas in back). Alright, Mr./Miss XYZ, everything sounds fine
and reassuring to me.
Fremitus
 I’ll just be placing the palms of my hand on the front and back of your chest to check for any abnormal
breathing sounds. When I place my hand please say and repeat 1, 2, 3 in each area. Perform this in 4 areas.
Alright, that was perfect.
Re-tie Gown
 Please pull up your gown and let me tie your gown for you.
Thank you!
 Thank you so much for your cooperation and patience! I’ll be sure to document this vital information! 
Back Examination
Mr./Miss XYZ, I’ll be examining your back now is that alright? For this, I have to untie your gown first. Please
adjust it to your comfort level.
Inspection
 I’m going to inspect your back for any deformities or swelling. (Inspect it) Well, your back seems
perfectly fine to me.
Palpation
 I’m going to be pressing on your back to feel for any pain or swelling. OH, I’m so sorry for causing you
pain, but let me inform you that this was a vital finding for me and will aid me in reaching a diagnosis for you.
Are you comfortable?
Range of Motion
 Mr./Miss XYZ, I’m going to check the movement of your back. Can you please bend forward, backward,
to the right side, and to the left side? 
Power
 Alright, I am going to examine your legs now. First I’m going to check the power in your legs. Please
resist my actions. Kick in and kick out your legs against my hands. Your muscle power seems fine to me on both
sides. 
Sensory
 I am going to I’m going to check the sensation of your legs. Pease let me know if you feel the touch like
this (demonstrate the touch). Did you feel the touch equally on both sides?
o If abnormality present, say “Oh ok I’ll be sure to make a note of this Mr./Miss XYZ.”
Reflexes
 I will check your reflexes by striking with this rubber hammer now. It would not hurt you, but please let
me know if you do and I will stop right away (check patellar and ankle reflexes).
Straight Leg Raise (SLR) Test
 I’ll be performing a test known as the straight leg raise test. It is used to check the integrity of the
supporting structures of the spine. It may cause a little pain, but let me assure you that it will aid me in
reaching the diagnosis.
o I’m going to help you lie down and pull out the foot rest for you (perform actions as you speak to him).
Please let me know if you feel any pain. Please relax your legs (raise his one legs up to 60 degrees and wait for
patient’s response).
 If positive then say: Oh, I’m so sorry to have caused you pain, but this was important information for
me. Are you comfortable?
 Can I do this on your other leg? (Do it if patients allows you)
o I’m going to help you sit up and tie your gown’s knot…push in the foot rest.
Thank you!
 Thank you so much for allowing me to do this examination and being so patient and cooperative! I will
definitely make sure to record all these vital findings.
Shoulder Examination
Mr./Miss XYZ, I’m going to be examining your shoulders now. I’ll examine both sides and will definitely consider
that your right shoulder is hurting you. I will need to expose both your shoulders so please adjust your gown up
to your comfort level after I untie it.
Inspection
 I am looking at both your shoulders for any skin changes, bruises, abnormalities, visible pulsation,
swelling, or scar marks (look)
 Alright, everything seems good to me except for some swelling on the right side. Don’t worry, however,
we will address it.
Palpation
 Alright. I am going to touch your shoulders now. Pease let me now if you feel any pain, I will stop right
away.
 (If the patient feels pain) Oh, I’m so sorry Mr./Miss XYZ for causing you pain, but this was a vital piece of
information and will help me make a definitive diagnosis.
Range of Motion
 I am going to check the movements on both sides. I just want to let you know before starting that this
may produce pain, but please let me know and I’ll stop right away.
 Perform extension, flexion, abduction, adduction, and circumduction of both shoulders joint.
 Mr./Miss XYZ, I see that you are having difficulties moving your right shoulder.
Power
 I am going to check the power in your arms now, so please resist my actions. (Perform abduction,
adduction, flexion, and extension with resistance)
Reflexes
 Now I’ll check your reflexes with this medical hammer made up of rubber. Please let me know if it
causes you any pain and I’ll stop right away.
Thank you!
Knee Examination
Mr./Miss XYZ, I am going to be examining your knees now. I will examine both knees so can you please relax
your legs.
Inspection
 First I am going to look at both your knees for any skin changes, color changes, abnormalities, swelling,
or scar marks (look).
 Alright, both knees seem good to me.
Palpation
 Alright, I’m going to touch your knees now. Pease let me now if you feel any pain and I’ll stop right
away.
 Palpate and look at the patients face.
 If the patient feels pain say: Oh, I am so sorry Mr./Miss XYZ, for causing you pain, but this was a vital
piece of information for me and will help me making a definitive diagnosis.
Range of Motion
 I am going to check the movements on both sides. I just want to let you know before starting that this
may produce pain, but please let me know and I’ll stop right away.
 Perform extension and flexion of the both knee joints.
 Ok, Mr./Miss XYZ, I see that you are having difficulties moving your right knee and I apologize for
causing you the pain.
Power
 I am going to check the power in your legs now, so please resist my actions.
 Perform extension and flexion of the both legs.
Anterior and Posterior Drawer Sign
 Okay, Mr./Miss XYZ, I am going to perform certain maneuvers known as the anterior and posterior
drawer sign which will check the integrity of the supporting structures of your knee. They may be painful but let
me assure you that it will be vital for me to make a diagnosis. Please if you feel any pain let me know and I’ll
stop right away.
 Perform the test (first on non-painful side and then on painful side if patients allows you to do that)
 So the supporting structures seem perfectly fine to me on the left side. Can I please perform it on the
right side? I know you’re experiencing pain on that side, but examining it will help me make my diagnosis (if the
patient experiences pain, STOP).
Thank you!
Mini Mental Exam Status (MMSE)
Mr./Miss XYZ I am going to be asking you a few questions which may seem an awkward to you, but they will
allow me to judge your overall mental status and orientation. Is that alright?
Orientation (AAO x 3)
 What is your full name?
 What is the date today?
 Where are you right now?
Immediate Memory
 I will name three objects: bat, mat, hat.
 Can you please repeat these words?
 Please remember them and I will ask you afterward.
Short Term Memory
 What did you have as your last meal?
Long Term Memory
 When did you graduate/get married?
Recall
 Can you please recall those 3 objects for me?
Concentration
 Can you please spell “CAR” backward?
Judgment
 If there is a fire in that corner, what will you do?
Thank you!
Alright, thank you so much Mr./Miss XYZ for your patience and cooperation. Your mental status, memory,
judgment and orientation seem fine to me.
The full MMSE is used in following cases:

 Dementia
 Hallucination
 ADHD
 Bipolar
 Hypomania
While only orientation part is used in following cases:

 Loss of Consciousness (LOC)
 Headache (Emergency)
Ear and Hearing Examination
Mr./Miss XYZ I am going to be examining your ear and test your hearing. Is that alright?
Inspection
 So, I am inspecting your ears. (Inspect) They seem perfectly fine to me with no bleeding, discharge, color
changes, or any swelling.
Palpation
 So, I will be touching your ears. Please let me know if you experience any pain and I will stop right away.
(palpate pinna, lobe, and cartilage).
Hearing
 Whisper Test: I will be rubbing my fingers in front of your both ears. (Rub fingers in front of ear) Did you hear
the sound? Was it equal on both ears?
Now, I will be performing two tests known as the Rinne and Weber test. These tests are used to check the
hearing.
o Rinne Test: This instrument is called a tuning fork and I’ll strike it against my palm then first I will place it
behind your right ear and then the front of it. I assure you it won’t hurt, but let me know in which area you hear
the better. (Strike tuning fork against your palm) Perform it on right side.
After performing on right side, now say: I am going to repeat in on your left ear as well.
o Weber Test: I will strike it again against my palm and will place it in the center of your scalp. (strike tuning fork
and place it in the center of scalp)
Can you hear it? In which ear you hear the better?
Thank you!
Alright, thank you so much for your patience and cooperation. Your hearing seems fine to me!
Patient Note Format
Name: __________________ Age: ________ Chief Complaint: _____________________________
Vital (Only Abnormal Ones): ____________________________________________________________
O S/G DD 1
F C/E
D m/D/M DD 2
P ↑/↓/→
DD 3
L UQ/LQ/Chest/Head
I 0/10 → 10/10 DD 4
Q Sh/Burn/Crampy
R +/- DD 5
A (↑) +/-
A (↓) +/- DD 6
A
DD 7
DD 8
DD 9
P HTN +/- Dr +/- M+/- C+/- (If age >50)

DM +/- Dr +/- M+/- C+/-
A +/- P
M +/- M
H +/- D
U +/- C
G +/-
S +/- N+/- V+/- F+/- W+/- (Any significant Physical Finding)
F Mother  Orthostatic Vitals

Father  Rectal and Pelvic Exam (in case of belly and
gynae/obs cases)
O LMP, Menarche, Cycle/Days of bleed, PAP  Fundoscopy (in HTN and DM cases)
S MG/PG x years. Contraception+/-  Gait Exam (In CNS and balance problem
cases)
S S Cig/D x Years  Otoscopy (in Hearing Problems)
A Glass/D x Years (± CAGE 0-4/4)  Breast Exam
D Type x years, Route, Last Dose
( + = Yes, - = No, +/- = Occasional)

USMLE STEP 2 Clinical
Skills Advance CS Notes
Authors: Furqan H. Syed & Ahmed Zahid
Revised & Edited by: R. Khalid & M. Shoaib
Advance CS Notes
Few Important Tips
 These notes must be combined with USMLE basic CS notes. These cover both typical as well
as atypical cases including the approach to difficult cases as well as their closures.
 Physical examination and labs are written on the basis of the DDs of the encounter.
 Mnemonics, as well as simple way to memorize DDs, are mentioned. Learn them as you
like.
 First work on fluency, then timing and then emotional component.
 Do maximum practice as much as you can.
 Ask common DDs based on your preliminary data of OFDPAA then ask rare/non-relevant
ones.
 Use normal pace at opening, transitional sentences, physical examination commands and
closure. For the rest, fast pace can be used.
 Use DDs after OFDPAA and before PAMHUGSFOSSS.
 First of all use OFDPAA for every complaint by asking an open-ended question.
 Use First Aid as well as helping tool.
 Start typing notes from day 1 and show it to seniors and type maximum as much you can.
 After you get fluency and enough practice with partner SP then do cases with other SPs as
well to get better approach and confidence. It will decrease PVA- Person Variant Anxiety.
In the end, we wish you best of luck for your exams and USMLE journey. And I want to thank
everyone who helped us in this.
Do remember us in your prayers.
Thanks.
Dr. Furqan Haider Syed

[email protected]
Dr. Ahmed Zahid
[email protected]
Table of Contents
Adult Cases
Upper Abdominal Pain ..............................................................................................................................
Diarrhea ....................................................................................................................................................
Blood in Stools ..........................................................................................................................................
Lower Abdominal Pain ..............................................................................................................................
Testicular Pain ...........................................................................................................................................
Knee Pain ................................................................................................................................................
Arm Pain..................................................................................................................................................
Back Pain .................................................................................................................................................
Neck Pain.................................................................................................................................................
Heel Pain .................................................................................................................................................
Hip Pain ...................................................................................................................................................
Calf Pain ..................................................................................................................................................
Chest pain ...............................................................................................................................................
Palpitations .............................................................................................................................................
Anxiety ....................................................................................................................................................
Cough ......................................................................................................................................................
SOB ..........................................................................................................................................................
Sore Throat .............................................................................................................................................
Hoarseness ..............................................................................................................................................
Jaundice ..................................................................................................................................................
Hematuria ...............................................................................................................................................
Burning Micturition .................................................................................................................................
Urinary Incontinence ..............................................................................................................................
Fatigue ....................................................................................................................................................
DM and HTN follow- up ..........................................................................................................................
Pre-Employment Exam ...........................................................................................................................
Headache ................................................................................................................................................
Forgetfulness ..........................................................................................................................................
Hearing Loss ............................................................................................................................................
Dizziness (Vertigo)...................................................................................................................................
Dizziness (LOC) ........................................................................................................................................
Seizures ...................................................................................................................................................
Menstrual Irregularities ..........................................................................................................................
Post-Menopausal Bleeding .....................................................................................................................
Vaginal Discharge ....................................................................................................................................
Dyspareunia ............................................................................................................................................
Sleep Problems/Insomnia .......................................................................................................................
Weight Gain ............................................................................................................................................
Weight Loss .............................................................................................................................................
Tremors ..................................................................................................................................................
Muscle Weakness ...................................................................................................................................
Hallucinations..........................................................................................................................................
Jaw Pain .................................................................................................................................................
ADHD ......................................................................................................................................................
Hypomania .............................................................................................................................................
Night Sweat ...........................................................................................................................................
Constipation ...........................................................................................................................................
Dysphagia ...............................................................................................................................................
Toe Discoloration....................................................................................................................................
Pediatric Case
Fever .......................................................................................................................................................
Seizures................................................................................................................................................
Diarrhea ...............................................................................................................................................
Cough ...................................................................................................................................................
Picky Eater ...........................................................................................................................................

Adult Cases
Upper Abdominal Pain
Differential Diagnosis: TRYS DHIBE
 Stomach:
Stomach:Gastritis, GERD,
Gastritis, Gastric
GERD, cancer
Gastric cancer
 Pancreas: Pancreatitis,
Pancreas: Pancreatic
Pancreatitis, Pancreaticcancer
cancer
LUQ: Hepatitis, Cholecystitis
 LUQ: Hepatitis, Cholecystitis
Questions
Gastritis
1. What Type of food aggravates the pain? Any use of NSAIDs?
2. Is there any Relationship between pain and timing of your food intake?
Hepatitis and Cholecystitis
3. Have you noticed any Yellowness of your eyes or skin?
4. Have you noticed any Distension of your belly?
GERD
5. Have you noticed any burning sensation in your chest (Heart Burn) or change in taste of your
mouth?
6. Have you ever been exposed to anybody with similar complaints (Infections)?
7. Have you noticed any change in Color of your stools or any Blood in the stools?
8. Any Change in your urine color or stool color?

9. Have you Eaten anything from outside recently?
Pancreas
10. Any h/o of weight loss?
11. Any h/o belly stones?
12. Any hx of malabsorption/diarrhea?
13. Any pain radiating to the back?
Exam
 HEENT
 GIT exam (including Murphy’s sign)
Investigations
1. Rectal & Pelvic Exam

2. Stool for occult blood
3. ALT/AST/Bilirubin/ALP
4. U/S Abdomen
5. Upper GI Endoscopy
6. HIDA scan
7. Noninvasive H. Pylori testing
Diarrhea
Differential Diagnosis: Watery, Bloody, Malabsorption
Watery: GC
Watery: GC PHAIL.
PHAIL. Gastroenteritis/Travelers,
Gastroenteritis/Travelers, Crohn’s
Crohn’s Disease,
Disease, Pseudomembranous
Pseudomembranous Colitis,
Colitis,
Hyperthyroidism, AIDS, IBS, Lactose Intolerance.
Hyperthyroidism, AIDS, IBS, Lactose Intolerance.
Bloody: Ulcerative
Bloody: Ulcerative Colitis,
Colitis, Dysentery,
Dysentery, Cancer.
Cancer.
Malabsorption: Pancreatitis,
Malabsorption: Pancreatitis, Giardiasis,
Giardiasis, Celiac
Celiac Disease.
Disease.
Questions
What do you mean by diarrhea? (You want to find out ---Do you mean increased frequency or increased
volume?)
What do your stools look like? (You want to find out --- Are they watery or bloody or fatty?)
For Watery Diarrhea:

1. For Gastroenteritis/Travelers’ Diarrhea:
a. Have you eaten outside recently?
b. Have you traveled recently?
2. For Crohn’s Disease:
a. Have you noticed a sense of incomplete evacuation after passing stools?
b. Have you noticed a pain in your belly?
3. For Pseudomembranous Colitis:
a. Have you been taking antibiotics recently?
4. For Hyperthyroidism: (Temp intolerance, Bowel movement)
a. Have you noticed racing of heart?
b. Have you noticed any skin changes?
c. Have you noticed any tremors of hands?
5. For AIDS: (IV drug abuse, low-grade fever, lymphadenopathy {lumps or bumps} in the body)
6. For IBS: (>3 months)
a. Have you noticed any relationship between belly pain to bowel movements?
b. Have you noticed any alternating diarrhea and constipation?
7. For Lactose Intolerance:
a. Have you noticed any relationship of diarrhea with any milk products?
For Bloody Diarrhea:

1. For Ulcerative Colitis:
a. Have you noticed a sense of incomplete evacuation after passing stools?
b. Have you noticed a pain in your belly?
c. Do you have to rush to defecate?
d. Have you noticed skin rash or joint pain?
2. For Dysentery: (fever, pain abdomen, nausea, eaten outside)
3. For Cancer: (weight loss, reduced appetite, may have belly pain also )
For Malabsorption:
Are your stools difficult to flush?
Are your stools foul smelling?
Have you noticed any change in your weight?
1. For Pancreatitis: (Alcoholic)

a. Do you have a Hx of gallstones?
b. Have you noticed belly pain going to the back?
2. For Giardiasis: (fever)
a. Have you been on a hiking trip recently? Or drank from the freshwater lake?
3. For Celiac Disease:
a. Have you noticed any relationship to wheat products or any specific food?
Exam
1. HEENT + Thyroid exam

2. GIT exam (including Murphy’s)
Investigations

2. Stool exam & fecal leukocytes
3. TSH, T3 & T4
5. U/S Abdomen
6. Colonoscopy
7. Serum immunoglobins
Blood in Stools
Differential Diagnosis: CHAD UF (Upper GI) LPG (Lower GI)
Anal:Anal
Anal: Analfissure,
fissure,Hemorrhoids
Hemorrhoids
Colon:Colon
Colon: ColonCancer,
Cancer,Angiodysplasia,
Angiodysplasia,Diverticulosis
Diverticulosis
Ileum:Ulcerative
Ileum: UlcerativeColitis,
Colitis,IBS/IBD
IBS/IBD
Stomach:Gastritis,
Stomach: Gastritis,PUD
PUD
Liver:CLD
Liver: CLD
Questions
Is the blood before, mixed or after passing stools?

What is the color of blood? (What you want to find out --Bright red or dark)
Have you vomited ever since? Does it contain blood? (Go to upper GI questions first)
Have you noticed any pain on passing stools? (Go to lower GI questions first)
1. For Colorectal CA: (weight and appetite changes, family Hx, changes in bowel movement)
a. Have you noticed any change in caliber/thickness of stools?
2. For Hemorrhoids: (Fresh blood)
a. Have you noticed anything coming out of /protruding from the anus?
3. For Angiodysplasia: (Age, Painless heavy bleeding)
4. For Diverticulosis: (Age, Painless heavy bleeding, constipation)
a. What does your primary diet comprise of? (lack of fiber)
5. For Ulcerative colitis: (Abdominal Pain)
a. Have you noticed a sense of incomplete evacuation even after passing stools?
b. Do you have to rush to defecate?
c. Have you noticed joint pain? Or redness of eyes?
6. For Anal Fissure: (Painful bleeding, constipation)
7. For Chronic Liver Disease: (N/V, Alcohol use, skin changes)
a. Have you noticed any distension of your belly?
b. Have you noticed enlargement of breasts?
8. For PUD: (Epigastric pain)
a. Is there any relationship between pain and timing of your food intake?
9. For Gastritis: (GERD, NSAIDs)
Exam
1. HEENT
2. GIT Exam
Investigations
1. Rectal & Pelvic Exam 4. Stool for occult blood

2. ALT/AST/Bilirubin/ALP 5. U/S Abdomen
3. Upper GI Endoscopy & Colonoscopy 6. Noninvasive H. Pylori testing
Lower Abdominal Pain
Differential Diagnosis: LMP RT CVS PAP & NV BB DIE
Genitourinary:
Genitourinary:
- - Uterus: endometriosis
Uterus: Endometriosis
- - Ovary:
Ovary:Ovarian cyst
Ovarian rupture,
cyst Adnexal
rupture, Torsion,
Adenexal Ectopic
Torsion, Pregnancy
Ectopic Pregnancy
GIT:
GIT:
- - Colon:
Colon:
Appendicitis,
Appendicitis,
Diverticulosis
Diverticulitis
- - Ileum:
Ileum:
IBD/IBS,
IBD/IBS,
Gastroenteritis
Gastroenteritis
Kidney:
Kidney:
- - Nephrolithiasis
Nephrolithiasis
Questions
Gastrointestinal
1. Do you feel Nauseated?

2. Have you Vomited ever since this illness?
3. Have you noticed any change in Bowel habits?
a. If yes, the EFI
i. Have you Eaten outside?
ii. Do you have Fever?
iii. Have you ever been exposed to anybody with similar complaints (Infection)?
4. Have you noticed any Blood in stools?
a. If yes, then ABCO
i. Amount
ii. Color & Clots
iii. Before, After or mixed with stools
iv. Odour
5. What sort of your Diet do you usually eat?
6. What is the relationship of pain with bowel movement? Any pain during the night? (IBS)
7. Have you noticed a sense of incomplete Evacuation? Joint pains or oral ulcers?
Genitourinary
Insert transitional statement for Gynae/ Obs questions.
1. When was your LMP?

2. When was your first Menstrual period (Menarche)?
3. Do you feel Pain during intercourse or defecation?
4. Are your cycles Regular?
5. How many Tampons/Pads do you use on a heavy day?
6. Have you noticed Crampy pain during menses?
7. Have you noticed any Vaginal discharge?
8. Have you noticed any Spotting in between periods?
9. Are you Pregnant?
10. Have you ever had Abortions?
11. When was your Last Pap smear?
Exam
1. HEENT
2. GIT exam (Rebound Tenderness)
Investigations

2. β-HCG
3. CBC with Differential, S/E
6. U/S Abdomen & CT scan Abdomen
7. Upper GI Endoscopy
8. Colonoscopy
9. Laparoscopy
Testicular Pain
Differential Diagnosis: WRS + THE OT
Testes:Torsion,
Testes: Torsion,Trauma
Trauma
Epididmis: Epididmitis
Epididymis: Epididymitis
Adnexa:Torsion,
Adnexa: Torsion,Hernia
Hernia
Questions
1. For Trauma: Do you have any hx of trauma to your genital area recently?
2. For Hernia:
a. Have you noticed anything coming into your scrotum?
b. Have you noticed any change in bowel habits?
c. Have you noticed any relationship of swelling to position or lying down?
3. For Epididymitis:
a. Have you noticed burning sensation while passing urine?
b. Do you have to urinate more frequently than usual?
c. Do you have to rush to urinate?
4. For Orchitis: (Fever)
a. Have you noticed swelling elsewhere in the body? (Parotid)
5. For Torsion: (Nausea)
a. Have you noticed pain in your belly?
b. Have you noticed your testicle in an abnormal position?
Exam
1. HEENT
2. GIT exam
Investigations

2. CBC with Differential, S/E
3. Urinalysis, Urine culture
4. U/S tests and abdomen.
Knee Pain
Differential Diagnosis: WRSS WNT CHOPF + CITRUS
Unilateral:Septic
Unilateral: Septicarthritis,
arthritis,Gout,
Gout,Pseudogout
Psuedogout
Bilateral:Osteoarthritis,
Bilateral: Osteoarthritis,Rheumatoid
RheumatoidArthritis,
Arthritis,SLE
SLE
Questions
1. Have you noticed any Warmth of your joint?

2. Have you noticed any Redness of your joint?
3. Have you noticed any Stiffness of your joint?
4. Have you noticed any Swelling of your joint?
5. Have you noticed any Weakness of your joint?
6. Have you noticed any Numbness or Tingling of your joint?
7. Have you noticed any disColoration of your fingers in the cold?
8. Have you noticed any Hair loss recently?
9. Do you have pain in any Other joint?
10. Have you noticed any Discomfort on Exposure to sunlight?
11. Do you feel more tired than usual (Fatigue)?
Exam
1. HEENT
2. Inspect, Palpate, ROM, Motor, Reflexes, Sensations, Pulses, Gait- Compare to the other side.
3. Knee maneuvers
Investigations
1. CBC with differential, S/E

2. ESR
3. Arthrocentesis and analysis
4. X-ray Knee AP & Lat. view
5. CT scan Knee
6. MRI Knee
7. DEXA scan
8. Ca++ & Vitamin-D levels
Arm Pain
Differential Diagnosis: WRSS WNT
Bone:
Bone:Fracture,
Fracture,Shoulder
ShoulderDislocation
Dislocation
Muscle: Muscle Strain
Capsule:
Capsule:Rotator
RotatorCuff
CuffTear,
Tear,Tendinitis
Tendinitis
Heart:
Heart:Angina,
Angina,MI
MI
Questions

7. Rule out MI by asking following questions.
a. Have you noticed any chest pain? If yes, does this pain go to any other part of the body?
b. Have you noticed any shortness of pain?
c. Have you noticed racing of heart?
d. Have you noticed any sweating?
Exam
1. HEENT
2. Inspect, Palpate, ROM, Motor, Reflexes, Sensations, Pulses - Compare to the other side.
Investigations

2. ESR
3. X-ray Shoulder/Arm AP & Lat view
4. CT scan Arm
5. MRI Shoulder
7. DEXA scan
Back Pain
Differential Diagnosis: WRSS WNT GLIP + CITRUS
With WNT:
Bone:WNT:
With Fracture, Osteoarthritis
Disk: Herniation, Spondylosis
Bone: Fracture, Osteoarthritis
Without WNT:
Bone: Bone
Without WNT:Cancer, Multiple Myeloma
Bone: Bone Cancer, Multiple Myeloma
Muscle: Muscle Strain SLE, RA
Supporting Structures:
Questions

7. Have you noticed any changes in your Gait?
8. Have you been Lifting any heavyweight recently?
9. Have you ever passes Urine/Stools without your knowledge? (Incompetence)
10. Have you noticed any effect of Position on pain?
Exam
1. HEENT
2. Inspect, Palpate, ROM, Motor, Reflexes, Sensations, Pulses, Gait
Investigations

2. ESR
3. X-ray spine AP & Lat view
4. CT scan
5. MRI
6. DEXA scan
8. RA factor, ANA
Neck Pain
Differential Diagnosis: WRSS WNT GLIPBP + CITRUS
WithWNT:
With WNT:
Bone:Fracture,
Bone: Fracture,Osteoarthritis
Osteoarthritis
WithoutWNT:
Without WNT:
Bone: Bone Cancer,Multiple
Bone: Bone Cancer, MultipleMyeloma
Myeloma
Muscle:Muscle
Muscle: MuscleStrain
Strain
Supporting Structures: RA,Meningitis
Supporting Structures: RA, Meningitis
Questions

7. Have you noticed any changes in your Gait?
8. Have you been Lifting any heavyweight recently?
9. Have you ever passed Urine/Stools without your knowledge? (Incompetence)
10. Have you noticed any effect of Position on pain?
11. Have you noticed any trouble Breathing?
12. Have you noticed any trouble in bright light? (Photosensitivity)
Exam
1. HEENT
Investigations

2. ESR
3. LP and analysis
4. BUN: Cr
5. SPEC
6. X-ray Neck AP & Lat view
7. CT scan
8. MRI
9. DEXA scan
11. RA factor, ANA
Heel Pain
Differential Diagnosis: WRSS WNT TWOFFP + PARC FAT
Bone:Calcaneal
Bone: CalcanealStress
StressFracture
Fracture
Muscle: Muscle Strain/Ankle
Muscle: Muscle Strain/Ankle StrainStrain
Fascia:Plantar
Fascia: PlantarFascitis,
Fasciitis, Ankylosing
Ankylosing Spondylitis
Spondylitis
Bursa: Retrocalcaneal Bursitis, Tarsal TunnelSyndrome
Bursa: Retrocalcaneal Bursitis, Tarsal Tunnel Syndrome
Skin: Foreign Body
Skin: Foreign Body
Questions

7. What Time does it hurt the most? (morning or evening)
8. Have you noticed any difficulty Walking?
9. What precipitates your pain? Walking or Jumping? (Overuse)
10. Have you ever had any Fracture?
11. Have you stepped on any pointed object? (Foreign Body)
12. Have you noticed any Popping sound?
Exam
1. HEENT
Investigations

2. ESR
4. X-ray Heel AP & Lat view
5. CT scan
6. MRI
7. DEXA scan
Hip Pain
Differential Diagnosis: WRSS WNT + BRASS OOF
Bone:
Bone: Fracture,
Fracture, OA/Osteoporosis
OA/Osteoporosis
Capsule:
Capsule: Bursitis, Septic
Bursitis, Septic Arthritis
Arthritis
Muscle:
Muscle: Muscle
Muscle Strain
Strain
Miscellaneous:
Miscellaneous: Referred
Referred pain,
pain, Steroid
Steroid Abuse,
Abuse, Arterial
Arterial Insufficiency
Insufficiency
Questions
1. For Bursitis:
a. Have you noticed pain when you lie on that side?
2. For Referred Pain:
a. Have you noticed pain elsewhere in the body?
3. For Arterial Insufficiency:
a. Have you noticed any problem maintaining an erection?
b. Have you noticed any improvement in pain if you rest after walking some distance?
4. For Sprain:
a. Have you lifted any heavyweights recently?
5. For Steroid/Drugs:
6. For Osteoarthritis (Stiffness):
a. Have you noticed any scratching sensations in your joint?
7. For Osteoporosis: (Menstrual Hx, Age, No HRT)
8. For Fractures:
a. Have you noticed nay trauma recently?
b. Have you been following a vigorous exercise plan recently?
Exam
1. HEENT
Investigations

2. ESR
4. X-ray Hip AP & Lat view
5. CT scan
6. MRI
7. DEXA scan
Calf Pain
Differential Diagnosis: WRSS VOIS + Decrease β-HCG Slowly
Muscle:Myositis/Cellulitis,
Muscle: Myositis/Cellulitis,Muscle
MuscleStrain
Strain
Vessels: DVT, Hematoma
Vessels: DVT, Hematoma
Other:Baker’s
Other: Baker’sCyst,
Cyst,Gastrocnemius
GastrocnemiusTendon
TendonRupture
Rupture
Questions

5. Have you noticed any Visible veins/pulsations?
6. Have you been Immobilized recently?
7. Are you using Oral Contraceptive Pills recently?
8. Have you noticed any Shortness of breath? Any Chest pain?
Exam
1. HEENT
2. Inspect, Palpate, ROM, Homan’s sign, Pulses,
3. Motor, Reflexes, Sensations of Ankle and Knee Joint
Investigations

2. ESR
3. D-dimer and FDPs
4. Doppler U/S
5. Arteriography and Venography
Chest pain
Differential Diagnosis: MP3 GC DC
Heart
Heart
- - Covering:
Covering:Pericarditis,
Pericarditis
- Muscle: Cardiomyopathy
- Muscle: Cardiomyopathy
- - Vessels:
Vessels:IHD/MI,
IHD/MI,Aortic
AorticDissection,
Dissection,Cocaine
CocaineAbuse
Abuse(vessel
(vesselspasm)
spasm)
Lung
Lung
- - Covering:
Covering:Peuritis
Pleuritis
- - Parenchyma:
Parenchyma:Pneumonia
Pneumonia
- - Vessel:
Vessel:Pulmonary
PulmonaryEmbolism
Embolism
Esophagus
Esophagus
- - GERD
GERD
Skin
Skin
- - Costochondritis
Costochondritis
Questions
1. For MI:
a. Have you noticed any Shortness of breath?
b. Is the pain associated with sweating? Racing of heart?
c. Has the pain improved after resting?
2. For Pericarditis:
a. Have you recently suffered from flu (a runny nose, watery eyes, sore throat,
fever, fatigue)?
b. Any relationship of pain to breathing?
3. For Pneumonia:
a. Have you ever been exposed to anybody with similar complaints?
b. Have you suffered from a cough recently?
4. For PE:
a. Have you noticed calf pain or swelling?
b. Have you been immobilized recently?
c. Are you using Oral Contraceptive Pills recently?
5. For GERD:
a. Have you noticed any burning sensation in your chest or change in taste of your mouth?
6. For Chostochondritis
7. For Aortic Dissection
8. For Cocaine Abuse:
Exam
1. HEENT
2. CVS and Pulmonary exam
Investigations
1. CBC with differential, S/E 5. EKG, Cardiac Enzymes

2. CXR 6. D-dimer and FDPs
3. Doppler U/S
4. Arteriography and Venography
Palpitations
Differential Diagnosis: CC FAGAT
CVS:Cardiac
CVS: Cardiacarrhythmias,
arrhythmias,Anemia
Anemia
Endocrine:Hyperthyroidism,
Endocrine: Hyperthyroidism,Hypoglycemia
Hypoglycemia
Other:Caffeine,
Other: Caffeine,Fever,
Fever,Anxiety/Pain
Anxiety/Pain
Questions
1. For Cardiac Arrhythmia:

a. Have you noticed any chest pain? SOB? Racing of heart? Skipped beats? Sweating?
2. For Caffeine:
a. Do you consume caffeinated beverages? If yes, then ask how much?
3. For Fever:
4. For Anxiety/Panic Disorder:
a. Is there any event associated with the racing of heart?
b. Does your breathing rate increase during the episode?
c. Do you feel dizzy during the episode?
5. For HypoGlycemia:
a. Do you have a Hx of High blood sugar level?
b. Have you skipped meals? Or changed any dose or medications recently?
6. For Anemia:
a. Have you noticed any change of skin color?
b. Have you noticed SOB on exertion?
c. Have you noticed excessive bleeding from any site of the body?
7. For HyperThyroidism: (Temp intolerance, Bowel movement)
Exam
1. HEENT
Investigations

2. EKG, Cardiac Enzymes
3. Holter Monitoring
4. BSL
5. TSH, T3 & T4.
Anxiety
Differential Diagnosis: PAPA HCG ST
Psychiatry:Panic
Psychiatry: PanicDisorder,
Disorder,ASD/PTSD,
ASD/PTSD,Adjustment
AdjustmentDisorder,
Disorder,GAD
GAD
Endocrine:Hyperthyroidism
Endocrine: Hyperthyroidism
Other:Caffeine,
Other: Caffeine,Substance
SubstanceAbuse
Abuse
Questions
1. For Panic Disorder:

a. Is there any particular event associated with the racing of heart?
b. Does your breathing rate increase during the episode?
c. Do you feel dizzy during the episode?
2. For Acute stress: (<1 months)
a. Have you experienced nightmares recently?
b. Have you experienced flashbacks?
3. For PTSD: (>1 month)
b. Have you experienced flashbacks?
4. For Adjustment: (Stress, Time more than 1 month)
5. For Hypochondriasis: (excessive preoccupation with disease)
6. For Caffeine:
7. For GAD:
a. Do you feel worried about something in particular or generally about everything?
8. For Substance Abuse:
9. For HyperThyroidism: (Temp intolerance, Bowel movement)
Exam
1. HEENT
Investigations

2. TSH, T3 & T4.
3. Urine toxicology screen.
Cough
Differential Diagnosis:
Non-Productive:
Non-Productive: Productive
Productivewithout
withoutBlood:
Blood: Productive
Productivewith
withBlood:
Blood:
A=
A=Asthma
Asthma A=CAP
A=CAP (Comm Acquire Pneum) A=
A=Aspriation
Aspiration
BB == Bronchitis
Bronchitis B=Bronchioectasis
B=Bronchioectasis B=
B= T.B.
T.B.
CC == Common
Common ColdCold C=CA
C=CA Lung
Lung C=
C= CCF,
CCF, COPD
COPD
DD == Drugs
Drugslike
likeACE-I
ACE-I
FF == Fibrosis
Fibrosis
GG == GERD
GERD
Questions
Is the cough associated with Phlegm production? If yes, then ABCO

 Amount
 Blood present or not
 Color of Phlegm
 Odor
1. Non-Productive Cough:
a. For Atypical Pneumonia: (Fever +)
b. For Acute Bronchitis: (Fever -)
i. Have you recently suffered from flu (a runny nose, watery eyes, sore throat,
fever, fatigue)?
c. For Asthma: (Nighttime awakening for asthma is at Dawn)
i. Is there any relationship with exercise or weather?
ii. Do you have any pets at home?
iii. Do you have to wake up at night to catch a breath? (If yes, timing at night)
d. For Fibrosis:
i. What do you do for your living? (Occupation)
ii. Have you ever been exposed to radiation or chemotherapeutic drugs?
e. For Drugs: (ACEi/ARBs)
f. For GERD:
i. Have you noticed any burning sensation in your chest (Heart Burn) or change in
taste of your mouth?
2. Productive, NonBloody Cough:

a. For COPD:
i. Have you noticed any Shortness of breath?
ii. Have you noticed any abnormal sound while breathing?
b. For CCF: (Nighttime awakening for asthma is after few hours of Sleep)
i. Do you have to use more pillows than usual?
ii. Do you have to wake up at night to catch a breath? (If yes, timing at night)
iii. Have you noticed any swelling of your feet?
c. For Aspiration: (Alcoholic person is a risk factor)
i. Have you experienced any loss of consciousness recently?
ii. Have you noticed any difficulty swallowing (Stroke)?
d. For Community Acquired Pneumonia (CAP): (Fever)
i. Have you ever been exposed to anybody with similar complaints?
ii. If yes, then ABCO.
3. For Productive, Bloody Cough:

a. For T.B: (PENT Questions)
i. When was your last PPD/Monteux? If yes, then result.
ii. Have you ever been Exposed to anybody with similar complaints?
iii. Have you experienced Night sweats?
iv. Have you Travelled recently (to endemic areas)?
b. For CA Lung: (Smoking, Weight loss, Appetite)
c. For Bronchiectasis:
i. Do you have to assume a specific position to produce phlegm?
Exam
1. HEENT
2. CVS and Pulmonary Exam
Investigations
1. Sputum stain, and culture.

2. CBC with Differential, S/E.
3. Blood Culture
4. CXR
5. CT scan Chest.
6. BAL.
SOB
Differential Diagnosis: (CAP)2 FAT
CVS:Heart,
CVS: Heart,Blood,
Blood,CCF,
CCF,Anemia
Anemia
Pulmonary:
Pulmonary:
-- Vessels:
Vessels:Pulmonary
PulmonaryEmbolism
Embolism
-- Parenchyma:
Parenchyma:Fibrosis,
Fibrosis,Pneumonia,
Pneumonia,TBTB
-- Airways:
Airways:Asthma,
Asthma,COPD,
COPD,Aspiration
Aspiration
Questions
1. For COPD:
a. Have you noticed any Shortness of breath?
b. Have you noticed any abnormal sound while breathing?
2. For CCF: (Nighttime awakening for asthma is after few hours of Sleep)
a. Do you have to use more pillows than usual?
b. Do you have to wake up at night to catch a breath? (If yes, timing at night)
c. Have you noticed any swelling of your feet?
3. For Aspiration: (Alcoholic person is a risk factor)
a. Have you experienced any loss of consciousness recently?
b. Have you noticed any difficulty swallowing (Stroke)?
4. For Asthma: (Nighttime awakening for asthma is at Dawn)
a. Is there any relationship with exercise or weather?
b. Do you have any pets at home?
c. Do you have to wake up at night to catch a breath? (If yes, timing at night)
5. For Pneumonia: (Fever)
b. If yes, then ABCO.
6. For Pulmonary Embolism:
a. Have you noticed calf pain or swelling?
b. Have you been immobilized recently?
c. Are you using Oral Contraceptive Pills recently?
7. For Fibrosis:
d. What do you do for a living? (Occupation)
e. Have you ever been exposed to radiation or chemotherapeutic drugs?
8. For Anemia:
9. For T.B:
a. When was your last PPD/Monteux? If yes, then result.
b. Have you ever been Exposed to anybody with similar complaints?
c. Have you experienced Night sweats?
d. Have you Travelled recently (to endemic areas)?
Exam
1. HEENT
2. CVS and Pulmonary Exam
Investigations
1. Sputum stain, and culture.

3. PEFR.
4. Sputum stain and culture.
5. Blood Culture
6. CXR
7. Spiral CT scan Chest.
Sore Throat
Differential Diagnosis: PHIGNS
Nose:
Nose:Post-nasal
Post-nasalDischarge
Discharge
Throat: Pharyngitis
Throat: Pharyngitis
Esophagus:
Esophagus:GERD
GERD
Infections:
Infections: HIV,IM,
HIV, IM,Scarlet
ScarletFever
Fever
Questions
Have you noticed any pain on swallowing?

Have you noticed any swellings in the neck?
Do you have to clear your throat frequently?
1. For Pharyngitis:
a. Have you noticed any pain or fullness in the ear?
b. Have you noticed any redness or discharge from eyes?
2. For HIV: (IV drug abuse, Fatigue, Sexual behavior)
3. For IM:
b. Do you feel more tired than usual?
c. Have you noticed any fullness or pain in the belly?
4. For GERD:
a. Have you noticed any burning sensation in your chest? Or change in taste of your mouth?
5. For Post Nasal Drip:
a. Have you noticed nasal stiffness?
b. Have you noticed recurrent cough?
Exam
1. HEENT
2. Inspect, Palpate, (Sinus Tenderness)
4. Abdominal Exam (for Splenomegaly)
Investigations

2. ESR
3. Rapid Strep Test
4. Monospot Test
5. ELISA
6. Western Blot
7. Endoscopy
Hoarseness
Differential Diagnosis: PM leaves CAP in LGH
Area Painful Painless

Local CA, Abuse Vocal Polyps
Neck Pharyngitis/Laryngitis ----
Chest GERD MS (Mitral Stenosis)
Questions
Have you noticed pain while speaking?
1. For Pharyngitis: (Painful)

b. Have you noticed any redness or discharge from eyes?
2. For Mitral Stenosis: (Painless)
a. Have you noticed any SOB?
b. Have you noticed any difficulty swallowing?
c. Do you have a Hx of rheumatic fever?
3. For Laryngeal CA: (Painful)-Smoking and Alcohol use.
4. For Abuse/overuse: (Painful)-Profession
5. For Polyp: (Painless)
6. For Laryngitis: (Painful)
a. Have you recently suffered from flu (a runny nose, watery eyes, sore throat)?
7. For GERD: (Painful):
a. Have you noticed any burning sensation in your chest (Heart Burn) or change in taste of
your mouth?
8. For Hypothyroidism (Painless): (Cold Intolerance)
a. Have you noticed any changes in the skin?
b. Have you noticed any changes in bowel movement?
Exam
1. HEENT + Thyroid
2. CVS Exam
Investigations
1. CBC with differential, S/E.

2. TSH, T3 & T4.
3. ECHO, EKG.
4. Throat swab.
5. CT scan chest.
Jaundice
Differential Diagnosis: O CAVA
Pre-Hepatic:
Pre-Hepatic:Hemolytic
HemolyticAnemia
Anemia
Hepatic:
Hepatic: Hepatitis– –Viral
Hepatitis and
Viral, Alcohol,
Alcohol andAutoimmune
Autoimmune
Post-Hepatic: Obstructive Jaundice, Pancreatitis
Post-Hepatic: Obstructive Jaundice, Pancreatitis
Questions
1. What is the Color of your stools?(Dark or Light)

2. What is the Color of your stools?(Dark or Light)
3. Have you noticed any Itching of the body?
4. Have you noticed any Pain in your belly?
5. Have you noticed any pain in Joints?
6. Have you Eaten out recently?
7. Have you noticed any Traveled recently?
8. Have you noticed any Relationship of pain to meals?
Exam
1. HEENT
2. GIT exam (Murphy’s)
Investigations

4. U/S Abdomen
5. Anti-HAV, HBsAg, Anti-HCV.
6. ERCP
7. HIDA scan
Hematuria
Differential Diagnosis: HITTERS
Painless:Hemolytic
Painless: HemolyticAnemia,
Anemia,Tumors,
Tumors,Exercise,
Exercise,Bleeding
BleedingDisorders
Disorders
Painful:Infections,
Painful: Infections,Trauma,
Trauma,Renal
RenalStenois
Stones
Questions
Is the blood before, mixed or after urination?

Have you experienced any sore throat recently?
Have you started any medications recently? (Cyclophosphamide etc)
1. For Hematologic Causes:

a. Have you noticed bleeding from any other site of the body?
b. Do you have any history of easy breathing?
2. For Infection/UTI:
a. Do you have to pass urine more frequently than usual?
b. Have you noticed any trouble holding urine?
c. Have you noticed any burning sensation while urinating?
d. Have you noticed any pain in your belly? If yes, then ask OFDPLIQRAA.
3. For Tumor (including BPH): (Smoking)
a. Do you have to strain during micturition?
b. Have you noticed any change in the urinary stream?
c. Do you have to wake up at night to urinate?
d. Do you feel a sense of bladder fullness even after passing urine?
4. For Trauma:
5. For Exercise: (What aggravates?)
6. For Renal (Glomerulonephritis):
a. Have you noticed any swelling on your body?
b. Have you noticed any Joint pain or rash on your body?
7. For Renal Stones:
a. Do you have any History of kidney stones?
Exam
1. HEENT
2. GIT exam – Renal Punch
3. CVS
Investigations
1. Rectal Exam
2. Urinalysis, Urine stain, and Culture
3. U/S and CT Abdomen
4. BUN: Cr
5. CBC with Differential.
6. PT and APTT
7. Cystoscopy
Burning Micturition
Differential Diagnosis: PAPU on CTV
Urethra:
Urethra:Urethritis,
Urethritis,Vulvovaginitis,
Vulvovaginitis,Allergic/Irritational
Allergic/Irritational
Urinary
UrinaryBladder:
Bladder:Cystitis,
Cystitis,Prostatitis
Prostatitis
Kidney:
Kidney:Pyelonephritis,
Pyelonephritis,Trauma
Trauma
Questions
Do you have to urinate more frequently than usual?

Do you have to rush to urinate?
1. For Pyelonephritis: (Fever with chills, Nausea)

a. Have you noticed any pain in your flanks/belly?
2. For Allergic/Irritational:
a. Have you recently changed your contraceptive method?
3. For Prostatitis:
a. Do you have a Hx of recurrent urinary symptoms?
b. Have you noticed pain around your genital region?
4. For Urethritis:
a. Have you noticed any discharge in urine, If yes ABCO?
5. For Cystitis:
a. Have you noticed pain in your (lower) belly?
6. For Trauma:
7. For Vulvovaginitis:
a. Have you noticed any discharge from vagina?
b. Have you noticed any pain during intercourse?
Exam
1. HEENT
2. GIT exam (CVA Tenderness)
Investigations
1. Rectal Exam
3. CT Abdomen
4. U/S Abdomen
5. BUN: Cr
6. CBC with Differential.
7. Cystoscopy
Urinary Incontinence
Differential Diagnosis: Motor Incontinence, Overflow incontinence, Stress incontinence, Urge
Incontinence.
Questions
Has it impaired performance of your daily activities?

Are you consuming more fluids than usual?
1. For Motor Incontinence:
a. Do you have to urinate more frequently than usual?
b. Do you have to rush to urinate?
2. For Overflow incontinence: (DM)
a. Have you ever suffered a trauma to your back?
b. Have you noticed any Weakness of your body?
c. Have you noticed any Numbness or Tingling of your body?
3. For Stress incontinence: (Hx of multiple SVDs, or Hx of pelvic surgeries)
a. Have you noticed problem holding urine while laughing, coughing, and sneezing?
4. For Urge Incontinence:
a. Have you noticed leakage of urine, which follows a sudden strong urge?
Exam
1. HEENT
2. GIT exam
Investigations
1. Rectal Exam
3. Q-Tip
4. Urodynamic Studies
5. Cystoscopy
Fatigue
Differential Diagnosis: I3M2P A3DHD & Sheehan’s Syndrome
Endocrine:DM,
Endocrine: DM,Hypothyroidism,
Hypothyroidism,Sheehan’s
Sheehan’sSyndrome
Syndrome
Infections: TB, HIV, IM, Malignancy
Infections: TB, HIV, IM, Malignancy
Psychiatry:Depression,
Psychiatry: Depression,Adjustment/PTSD
Adjustment/PTSD
Other:Anemia,
Other: Anemia,Apnea,
Apnea,Myasthenia
Myasthenia
Questions
1. For Infections:
a. T.B: (PENT Questions)
b. I.M: (Ill contact, Pain Abdomen)
c. HIV: (Ill contact, IV drug abuse, Irresponsible sexual behavior)
2. For Myasthenia Gravis:
a. How does it progress during the day?
b. Have you noticed weakness of muscles or double vision?
3. For (occult) Malignancy: (Weigh loss)
a. Have you noticed any pain in your belly?
4. For PTSD: (Sleep changes, Stress/ Trauma)
5. For Apnea:
a. Do you snore at night? Or has someone told you?
b. Do you feel restless at night? Or has someone told you?
6. For Anemia:
7. For Adjustment: (Stress, Time more than 1 month)
8. For Depression: (Mood + SIGECAPS)
9. For Hypothyroidism: (Temp Intolerance, Skin Changes, Bowel changes)
10. For Diabetes Mellitus:
a. Do you feel more thirsty than usual?
b. Do you have to urinate more frequently than usual?
11. For Sheehan’s Syndrome:
a. Was the delivery normal? Or there was any excessive bleeding?
b. How many pints of blood were transfused?
c. Were you able to lose your weight after delivery?
d. Have you been able to breastfeed your child?
Exam
1. HEENT + Thyroid Exam

2. Orientation
Investigations
1. CBC with differential.

2. TSH, T3, and T4.
3. Monospot
4. ELISA
5. CXR
6. BSL
7. Acetylcholine receptor antibody.
8. CT scan Brain.
9. MRI Brain.
DM and HTN follow- up
After the introduction, ask the following questions:
(Note: this approach can be used in any case of drug refills like blue pills, OCP refill, and
diabetes/hypertension medication refill)
You: How can I help you today?

S/P: Doctor these are my medications please fill them for me!
You: Oh, surely I will give you the refills and I know these are very important for you. But Mr./Miss XYZ
as this is our first encounter and I don't have access to your previous medical records so let me ask a
few questions so that I can get have a better idea what is going on with you. Is that ok? So, do you have
any active complaint at the moment?
S/P: If the patient says yes, then go to OFDPAAA and DDs of that complaint.
If the patient says that he has no active complaint, then say: It’s very nice to know that! May I ask for
which reason you were using this medication? OR you can say that my nurse told me that your blood
pressure is on the higher side so I am concerned if your blood pressure/diabetes is controlled with
these medications or not. That’s why I will need to ask a series of questions so that I can get a better
idea of whether to change or add the new medications. Is that alright, Mr./Miss XYZ? I'll be very quick
and gentle.
Askabout
Ask aboutsymptoms
symptomsininfollowing
followingsystems.
systems:Eye,
Eye,Heart,
Heart,Stomach,
Stomach,Kidney,
Kidney,Perineum,
Perineum,Legs,
Legs,Foot;
Foot;Neuro,
Neuro,If
If Erectile
Erectile Dysfunction,
Dysfunction, then
then ask:
ask: Psychological
Psychological causes,
causes, Vascular,
Vascular, Depression,
Depression, Drugs.
Drugs
For how long? Taking Meds? Compliant? Side effects? Check BSL regularly? Under control? Last
reading? Last visit to the doctor? What was your last HBA1c?
1. For Eyes:
a. Have you noticed any changes in your vision?
b. When was your last eye checkup?
2. For Heart: (Past Hx of MI, SOB, Pacing of heart, Chest pain, Sweating)
3. For Pulmonary: (SOB)
4. For GIT: (Bowel habits, Polyphagia, Abnormal Discomfort-GERD)
5. For Genitourinary: (Polyuria, Polydipsia)
6. For Neuro: (Past Hx of Stroke or TIA, WNT, Speech or swallowing difficulty)
7. For Sexual:
a. Have you noticed any change in your sexual Desire?
b. Have you noticed any change in your sexual Performance? If yes, then ask;
c. Psychological causes
i. When did it start?
ii. How is the relationship with your spouse?
iii. Do you have morning erections?
iv. On a scale of 1 to 10, where 1 being flaccid & 6 being adequate for
penetration, How do you grade your erection?
v. Are you under any sort of excessive stress these days?
d. Vascular causes:
i. Have you noticed any pain in your legs?
ii. Have you noticed any Weakness of your body?
iii. Have you noticed any Numbness or Tingling of your body?
e. Depression (Mood + SIGECAPS)
f. Medications (are you taking any drugs?)
g. Hypogonadism: (desire issue)
i. Do you have normal pubic and axillary hair?
Exam
1. HEENT + Fundoscopy
2. CVS Exam
Investigations

2. CXR
3. BSL and HBA1c
4. Urine for Microalbumin, Urinalysis.
Pre-Employment Exam
After the introduction, ask so how can I help you today?
S/P: Doctor please fill this form.
You: (If the patient is starting a new job, then congratulate him and if this is a routine examination, then
simply counsel him.)
Congratulations Mr. XYZ on your new job and I hope you will do great.
You don’t need to worry, its just a routine examination of the employees either before starting the job
or during the job for screening purposes and surely I will fill this form. I have also received this form from
your employer and have filled such forms many times. Let me ask a few questions about your health so
that I can fill this form in a better way.
Askabout
Ask aboutsymptoms
symptomsininfollowing
followingsystems:
systems:Head,
Head,Eye,
Eye,Ear,
Ear,Nose,
Nose,Mouth,
Mouth,Neck,
Neck,Heart,
Heart,Stomach,
Stomach,Kidney,
Kidney, Perineum,
Perineum, Extremities,
Extremities, Foot, Psychiatric,
Foot, Psychiatric, Skin. Skin.
For how long? Taking Meds? Compliant? Side effects? Check BSL regularly? Under control? Last
reading? Last visit to the doctor? What was your last HBA1c?
1. For Head:
a. Do you have a Hx of head trauma?
b. Do you have a Hx of Dizziness, LOC/ fainting spells?
c. Do you have a Hx of Stroke or TIA?
d. Do you have a Hx of seizures?
2. For Eyes:
3. For Ear:
a. Have you noticed any changes in your hearing?
b. Have you noticed any problem with your balance or gait?
4. For Sinus:
a. Have you noticed chronic facial pain or nasal stuffiness?
5. For Neck:
a. Have you noticed any pain or swellings in your neck?
6. For Heart: (Past Hx of MI, SOB, Pacing of heart, Chest pain, Sweating)
7. For Pulmonary: (SOB, Cough)
8. For GIT: (Pain, distension, Bowel habits, Polyphagia, Abnormal Discomfort-GERD)
9. For Genitourinary: (Polyuria, Polydipsia)
10. For Obs/Gynae: (LMP RT CVS PAP)
11. For Psychiatric:
a. Do you have a Hx of psychiatric illness or admission?
12. For Skin:
a. Have you noticed a rash or any other skin problems?
Exam
1. HEENT
2. Relevant Exam
Investigations
1. MMSE – orientation
2. Kerning and Brudinzki Maneuver
3. CXR
4. Urinalysis.
Closure
Mr. XYZ thank you for your patience and cooperation. Depending on the history and PE, I am considering
a number of possibilities of your current complaint that it might be due to ______________, but I am
not sure right now. For this, I will have to run some tests that will include some blood work up like a
complete blood count and some imaging studies like X-ray or CT of your chest. When the results are
available, we will sit together and discuss the further management plan and you don’t need to worry
since you are in safe hands. Meanwhile, I am KUO and I would advise you to wear masks, maintain
contact precautions, and cough into a napkin. My nurse is going to come and take some blood to run
some tests and when the labs are available, then I will be in a better position to fill this form and then I
will contact you. I might have to report it to Center for Disease Control if it something infectious like
tuberculosis.
C/Q: Doctor will my boss fire me if he finds out this is T.B.?
You: Thank you for sharing your concern with me, but let me inform you that per the labor law of the
U.S., you employer cannot fire you on the basis of this disease and you have legal protection, but I have
to report it to the CDC so that they can take care of you as well as maintain the record.
Headache
Differential Diagnosis: M2CB R S2T4D GC (MCB owner had Resistant STDs in GC)
Primary:Migraine,
Primary: Migraine,Cluster
ClusterHeadache,
Headache,Tension
TensionHeadaches
Headaches
Secondary:
Secondary:
Nose:Sinusitis
Nose: Sinusitis
Eye:Glaucoma,
Eye: Glaucoma,Refractive
RefractiveErrors
Errors
Temple: Temporal Arteritis
Temple: Temporal Arteritis
Skull:Injury
Skull: InjuryFracture
Fracture
Meninges: Meningitis, SubarachnoidHemorrhage
Meninges: Meningitis, Subarachnoid Hemorrhage(SAH)
(SAH)
Brain:Tumor,
Brain: Encephalitis,
Trauma, Tumor, Trauma,
TIA, Benign TIA, Benign
Intracranial Intracranial HTN
HTN
Questions
1. For Migraine: (ANP)
a. Have you noticed any unusual symptoms before the onset of headache (Aura)?
b. Do you feel Nauseated or like vomiting?
c. Are you abnormally sensitive to light/sound?
d. Any relationship of headache to menses?
2. For Meningitis/Encephalitis:
a. Have you noticed any pain or stiffness in the neck?
b. Have you noticed any rash on your body?
3. For Cluster Headache:
a. Do you have a runny nose?
b. Have you noticed any redness or discharge from eyes? Or pain in the back of eyes?
4. For Benign Intracranial HTN:
b. Are you using Oral Contraceptive Pills recently?
5. For Refractive Errors: (Vision Changes)
a. Have you noticed any pain with reading or concentrating?
6. For Sinusitis: (Runny nose, Sore throat)
a. Have you noticed any pain in the face?
b. Have you noticed any relationship between timing to the pain? (Morning or Evening)
7. For Subarachnoid Hemorrhage: (Neck Stiffness, Vision Changes, Nausea/ Vomiting)
8. For Temporal Arteritis: (Vision Changes, Fatigue)
a. Have you noticed any pain while chewing or combing hair?
b. Have you noticed any muscle stiffness?
9. For TIA: (WNT, Gait, Vision)
a. Have you noticed any problem swallowing?
b. Have you ever lost consciousness?
10. For Trauma/Subdural Hematoma:
11. For Tumor: (Weight loss, Appetite, Family Hx, Night headache)
12. For Tension Headache: (Excessive Stress, Vase like tightening)
13. For Glaucoma: (Vision Changes, Pain in eye, predisposing factor)
14. For Cocaine Abuse:
Exam
1. MMSE – Orientation
2. Inspect, Palpate of Head, ROM of Neck
3. CNS with Cranial Nerves
4. Motor, Reflexes, Sensation, Pulse, Gait and Lower Limb Upper Limb
5. Kerning and Brudinzki Maneuver
Investigations

2. ESR
3. CT Scan
4. LP and Analysis
5. Visual Acuity
Forgetfulness
You: So how can I help you today?

S/P: I am feeling fine. My daughter sent me here.
You: Where is she now?
S/P: She’s at home/parking the car.
You: Has she left some instructions/note for me?
Take the note and read it. Rephrase what it says to the S/P and ask the following questions:
1. Activity of daily life

 Are you able to bathe?
 Do you need help to use the toilet?
 Are you feed yourself?
 Can you dress?
 Can you get in and out from your bed?
2. Executive functions
 Can you cook?
 Can you shop by yourself?
 Who manages your accounts?
 Do you need any help with housework?
After asking all these questions, if the patient has true dementia ask OFDPAA of his complaints. Then use
the following mnemonic:
Differential Diagnosis: AN SVD in HBL
Diet Vit B12 Deficiency, Hypothyroidism

Reversible
Depression, Normal Pressure Hydrocephalus, Subdural
Organic
Hematoma
Irreversible Younger Age Vascular Dementia, Lewy Body Dementia
Old Age Senile Dementia, Alzheimer’s Dementia
Questions
1. For Alzheimer’s Dementia: (Age, Family Hx)

2. For Normal Pressure Hydrocephalus:
a. Have you noticed any changes in your gait?
b. Have you ever passed urine without your knowledge?
3. For Subdural Hematoma:
a. Do you have any recent Hx of fall or trauma to head?
4. For Vascular Dementia:
a. Have you noticed any Weakness of your body?
b. Have you noticed any Numbness or Tingling of your body?
c. Have you noticed any difficulty with speech?
a. How is your mood these days?
b. Have you noticed any changes in your Sleep? If yes, ask about early morning awakening?
Trouble falling asleep? Staying Sleep?
c. Do you enjoy the activities that you used to enjoy previously? (Interest)
d. Do you feel Guilty about anything?
e. Do you feel as Energetic as before?
f. Concentration Qs? Serial 7s or spell backward.
g. Have you noticed any change in your Appetite?
h. Psychomotor retardation?
i. Have you ever thought about Suicide? Have you ever planned or attempted suicide?
6. For Hypothyroidism? (Cold Intolerance)
a. Have you noticed any changes in the skin?
b. Have you noticed any changes in bowel movement?
7. For Vitamin B12 Deficiency:
a. What does your primary diet comprise of?
8. For Lewy Body Dementia:
a. Have you noticed any tremors in your hands?
b. Have you noticed any stiffness of your body?
c. Have you noticed any slowing of your body movements?
9. For Delirium: Ask Dehydration Qs (Heat stroke or Diarrhea)
Exam
1. In MMSE:
2. CNS exam (Motor, Reflexes, Sensory, Gait, MMSE)
Investigations

2. TSH, T3, and T4.
3. CT scan Brain.
4. MRI Brain.
5. Vitamin B12 level.
Closure
Mr. XYZ thank you for your patience and cooperation. Depending on the history and PE, I am considering
a number of possibilities of your current complaint that it might be due to ______________, but I am
not sure right now. For this, I will have to run some tests that will include some blood work up like a
complete blood count and some imaging studies like CT scan of your brain. When the results are
since you are in safe hands. Meanwhile, I am KUO and with your permission, I would like to involve your
family members and tell them about your condition so that they can take care of you in a better way.
You should not go out unaccompanied, keep an I.D. with you always, and don’t drive. I would also like
you and your family to meet with a social worker to assess your home supervision and safety measures.
The social worker will also inform you about the resources available in your community and you can
contact me anytime and by any means for your help and support.
Hearing Loss
Differential Diagnosis: PD of IPL in COMA
With Balance Problems PALM Perilymphatic Fistula, Acoustic Neuroma,

Labyrinthitis, Meniere’s disease
Without Balance Problems OCP Drugs Otosclerosis, Cochlear Nerve Damage, Presbycusis,
Drugs
Do you have any problems maintaining balance?
1. For Perilymphatic Fistula: (Trauma + Balance)

2. For Acoustic Neuroma:
a. Have you noticed any problem in localizing sounds?
b. Have you noticed any problem with your gait or balance?
3. For Labyrinthitis: (URI + Hearing loss + Balance)
4. For Meniere’s disease:
b. Have you noticed any ringing sounds in your ears?
c. Have you noticed any problem with your balance?
5. For Presbycusis: (Age)
a. Is the hearing lost for all sounds or for any specific sounds?
b. Have you noticed any problem understanding speech?
c. Do the word sound jumbled or distorted?
6. For Drugs:
7. For Infections:
a. Have you noticed any ear pain or discharge?
8. For Cochlear Nerve Damage:
a. Are you exposed to loud sounds at home or work?
9. For Otosclerosis: (Age, starts from one ear and progresses to other)
a. Have you noticed any problem hearing a whisper?
Exam
1. Ear – Inspection, Palpation, Whispers Test

2. Weber & Rhine’s test + Otoscopy
Investigations
1. CBC with differential + S/E.

2. Audiometry & Tympanometry.
3. CT scan Brain.
4. MRI Brain.
5. Brainstem Auditory evoked potential
6. VDRL
Dizziness (Vertigo)
Differential Diagnosis: BV PALM
With Hearing Problems PALM Perilymphatic Fistula, Acoustic Neuroma,

Labyrinthitis, Meniere’s disease
Without Hearing Problems BV Benign Positional Vertigo, Vestibular Neuronitis
Questions
What do you mean by dizziness? Have you noticed any problem in hearing?
Have you ever lost consciousness? If yes, then go to LOC case on next page.
1. For Benign Positions Vertigo:

a. Have you noticed any relationship to the position?
2. For Vestibular Neuronitis: (Nausea + Vomiting)
a. Have you recently suffered from flu (a runny nose, watery eyes, sore throat,
fever, fatigue)?
3. For Meniere’s Disease:
a. Have you noticed any ringing sounds in your ears?
b. Have you noticed fullness of your ears?
4. For Labyrinthitis: (Vestibular Neuronitis + Hearing loss)
5. For Acoustic Neuroma: (Family Hx + hearing loss + weight loss/appetite)
a. Have you noticed any problem with your gait?
6. For Perilymphatic Fistula:
a. Have you noticed or have any head trauma?
Exam
1. HEENT + Weber & Rhine’s test

2. CNS Exam (Cerebellar exam)
Investigations

2. Audiometry.
3. CT scan Brain.
4. MRI Brain.
Dizziness (LOC)
After introduction ask the following questions:
(AuSTIC):
a. Did you sense anything unusual before passing out? (Aura)
b. Did anyone notice jerky movements? (Shaking)
c. Did you bite your Tongue while shaking?
d. Did you pass urine without your knowledge?
e. Were you confused after you regained consciousness?
After asking AuSTIC, ask:

So was this a single episode or have you had others in the past?
If there is a single episode, then go directly to the mnemonic without asking OFPAA, but if the patient
has multiple episodes in the past, then ask OFDPAA first and then go to mnemonic. In the case of
negative AuSTIC, the DD would be HADCAMPUS while in the case of positive AuSTIC, the DD would be
VITAMINS D.
O How did these episodes start?

F Since they started, are they occurring more frequently or not?
D What is the duration of the last episode?
P Is the duration constant or changing?
A Anything making these episodes better?
A Or worse?
Now use your mnemonic depending on the basis of AuSTIC.

(Note: number of episodes dictates OFDPAA while AuSTIC dictates the DD which would be used)
Differential Diagnosis: HAD CAMPUS
CVS:Cardiac
CVS: Cardiacarrhythmia,
arrhythmia,Aortic
AorticStenosis,
Stenosis,Orthostatic
OrthostaticHypotension
Hypotension
CNS:Hypoglycemia,
CNS: Hypoglycemia,Alcohol
AlcoholWithdrawl,
Withdrawl,Mass
Mass(SOL),
(SOL),Seizure
Seizure
Other:Panic
Other: Panicattack,
attack,Unexplained
Unexplained(vasovagal
(vasovagalsyncope)
syncope)
Questions
1. For Hypoglycemia: (sweating, Nausea, racing of heart)

Do you have a Hx of High blood sugar level?
Have you skipped meals? Or changed any dose or medications recently?
2. For Alcoholic withdrawal: (Ask about alcohol use)
When was your last drink?
3. For Dehydration: (DMG)
Have you noticed any changes in bowel habits?
Have you noticed any meds or dosages?
How many pads do you use on a heavy day?
4. For Cardiac Arrhythmia:
Have you noticed any chest pain? SOB? Racing of heart? Skipped beats? Sweating?
5. For Aortic Stenosis: (SOB, Chest pain)
6. For Mass (Malignancy, Abscess, Lymphoma):
Have you noticed any Weakness of your body?
Have you noticed any Numbness or Tingling of your body?
Have you noticed any headache? If yes, what time of day?
7. For Panic Attack: (chest pain, SOB, racing of heart, Nausea, Vomiting)
How did this happen, please tell me more about it?
8. For Unexplained (Vasovagal Syncope): (Nausea, vomiting)
How did this happen, please tell me more about it?
9. For Seizures (AuSTIC):
Did you sense anything unusual before passing out? (Aura)
Did anyone notice jerky movements? (Shaking)
Did you bite your Tongue while shaking?
Did you pass urine without your knowledge?
Were you confused after you regained consciousness?
10. For Convulsive Syncope;
11. For Metabolic derangement (Electrolyte imbalance etc.):
Exam
1. MMSE – Orientation Only (AAO)
2. CVS Exam
3. CNS Exam
Investigations

2. EKG, ECHO
3. BSL
4. CT scan Brain.
5. MRI Brain.
Closure
Mr./Miss XYZ thank you for your patience and cooperation. Depending on the history and PE, I am
considering a number of possibilities of your current complaint that it might be due to ______________,
but I am not sure right now. For this, I will have to run some tests that will include some blood work up
like a complete blood count and some imaging studies like CT scan of your brain. When the results are
since you are in safe hands. Meanwhile, I am KUO and my nurse is going to give you some fluids so that
you don’t feel dizzy anymore. Meanwhile, I would advise you that you should not go out
unaccompanied, keep an I.D. with you always, and don’t drive until labs are available.
(In case of hypoglycemia) Keep a candy or granola bar with you and eat them whenever you feel dizzy.
You should be careful when you stand up or walk. Use hand railings whenever possible.
Seizures
After introduction ask the following questions:
(AuSTIC):
f. Did you sense anything unusual before passing out? (Aura)
g. Did anyone notice jerky movements? (Shaking)
h. Did you bite your Tongue while shaking?
i. Did you pass urine without your knowledge?
j. Were you confused after you regained consciousness?
After asking AuSTIC, ask:

So was this a single episode or have you had others in the past?
If there is a single episode, then go directly to the mnemonic without asking OFPAA, but if the patient
has multiple episodes in the past, then ask OFDPAA first and then go to mnemonic. In the case of
negative AuSTIC, the DD would be HADCAMPUS while in the case of positive AuSTIC, the DD would be
VITAMINS D.
O How did these episodes start?

F Since they started, are they occurring more frequently or not?
D What is the duration of the last episode?
P Is the duration constant or changing?
A Anything making these episodes better?
A Or worse?
Now use your mnemonic, depending on the basis of AuSTIC.

(Note: number of episodes dictates OFDPAA while AuSTIC dictates the DD which would be used)
Differential Diagnosis: VITAMINS D
Vascular,
Vascular,Infections
Infections(Meningitis,
(Meningitis,Encephalitis,
Encephalitis,Abscess),
Abscess),Trauma,
Trauma,Autoimmune
Autoimmune(SLE),
(SLE),Metabolic
(hypoglycemia, hyponatremia),
Metabolic (hypoglycemia, Idiopathic, Neoplasms,
hyponatremia), Idiopathic, pSychiatric,
Neoplasms,Drug Abuse/Withdrawal.
pSychiatric, Drug
Abuse/Withdrawal.
Questions
1. For Vascular problem: (DM, HTN)

a. Have you noticed a weakness, numbness of tingling of your body?
2. For Infections: (Fever)
a. Meningitis: Neck stiffness
b. Encephalitis: Confusion, LOC
c. Abscess: WNT
3. For Trauma:
4. For Autoimmune:
a. SLE: Have you noticed any rash or joint pain?
5. For Metabolic derangement:
a. Hypoglycemia: (DM, changes in medication or dosages)
b. Hyponatremia:
i. Have you had diarrhea recently?
ii. Are you feeling more thirsty than usual?
6. For Idiopathic:
7. For Neoplasms: (weight loss)
a. Have you noticed any headache or changes in vision?
8. For pSychiatric: (No Postictal confusion)
a. Are you under excessive stress these days?
9. For Drug Abuse/Withdrawal: (Alcohol, Benzodiazepine)
Exam
1. MMSE – Orientation Only (AAO)

2. CNS Exam
Investigations
1. CBC with differential, S/E (K+)

2. Urine Toxicology screen
3. Blood Culture
4. Lumbar puncture & CSF analysis
Closure
Mr./Miss XYZ thank you for your patience and cooperation. Depending on the history and PE, I am
since you are in safe hands. Meanwhile, I am KUO and my nurse is going to give you some fluids so that
you don’t feel dizzy anymore and a new pair of pants as well. Meanwhile, I would advise you that you
should not go out unaccompanied, keep an I.D. with you always, and don’t drive until labs are available.
You should be careful when you stand up or walk. Use hand railings whenever possible.
Menstrual Irregularities
After introduction ask OFDPAAA of the complaint, then ask LMP RT CVS PAP, and then use the
mnemonic:
Differential Diagnosis: PHATA PEPA
Hypothalamus:Anorexia,
Hypothalamus: Anorexia,Anxiety,
Anxiety,Exercise
Exercise
Pituitary: Prolactinoma, Hyperprolactinoma
Pituitary: Prolactinoma, Hyperprolactinoma
Thyroid:Thyroid
Thyroid: ThyroidProblems,
Problems,Anxiety
Anxiety
Ovary: PCOS, Premature Ovarian
Endometrium: Asherman Syndrome, Failure
Pregnancy
Endometrium:
Ovary: AshermanOvarian
PCOS, Premature Syndrome, Pregnancy
Failure
Questions
1. For Pregnancy:
a. Have you noticed any fullness or tenderness of breast?
2. For Hyperprolactinemia:
a. Have you noticed any discharge from the nipples?
b. Have you noticed any change in your vision recently?
c. Have you noticed any a headache recently?
d. Have you started any new medications recently?
3. For Anorexia: (weight/appetite changes)
a. How do you feel about this problem?
b. How do you feel about your physical appearance?
4. For Thyroid
a. Have you noticed any changes in your skin texture?
5. For Anxiety:
a. Are you under any sort of excessive stress these days?
6. For Premature ovarian failure:
a. Have you noticed episodes of increased warmth of the body?
b. Have you noticed any itching/dryness of your genital region?
7. For Exercise:
a. Are you following a vigorous exercise plan recently?
8. For Asherman Syndrome:
a. Have you ever had a gynecological procedure recently?
b. Have you ever had problems conceiving?
9. For PCOS:
a. Have you noticed any excessive hair growth recently?
b. Have you noticed any abnormal pigmentation of the body?
Exam
1. HEENT
2. Abdominal Exam
Investigations
1. Rectal & Pelvic Exam 4. FSH: LH

2. β-HCG 5. U/S Abdomen
3. CBC with differential, S/E 6. CT & MRI Brain
Post-Menopausal Bleeding
mnemonic:
Differential Diagnosis: ICE PACT
Vagina:Atrophic
Vagina: AtrophicVaginitis,
Vaginitis,Trauma
Trauma
Cerix: CA Cervix, Polyp, Infections
Chris: CA Cervix, Polyp, Infections
Endomterium:Endometrial
Endometrium: EndometrialHyperplasia,
Hyperplasia,CA
CAEndometrium
Endometrium
Questions
1. For Infections: (fever + pain)

a. Have you noticed any discharge from vagina? If yes, then ABCO
2. For CA Cervix: (weight loss)
a. Have you noticed any bleeding after intercourse?
3. For Endometrial Hyperplasia:
a. Are you taking HRT?
4. For Polyp:
a. Have you noticed anything coming out of the vagina?
5. For Atrophic Vaginitis:
6. For CA Endometrium:
b. Are you taking any medication for menopause?
7. For Trauma:
Exam
1. HEENT
2. Abdominal Exam
Investigations

2. β-HCG
4. Blood Culture
5. FSH: LH
6. U/S Abdomen
7. Pap smear
8. Endometrial Biopsy
Vaginal Discharge
mnemonic:
Differential Diagnosis: PVCAT or ATV on PC
Vagina:Atrophic
Vaginitis,Bacterial
BacterialVaginosis
Vaginosis
Cervix:
Cervix:Trichomonas,
Trichomonas,Candidate
Candidial Infection
Infection
Uterus:
Uterus:PID
PID
Questions
Have you noticed any redness or itching of your genital region? If yes, then ABCO.
 Amount
 Blood present or Not
 Color of discharge
 Odour
1. For Atrophic Vaginitis:
2. For Trichomonas: (Multiple sexual partners, Greenish discharge, Treat male partner)
3. For Bacterial Vaginosis: (Grayish discharge)
a. Have you been taking antibiotics recently?
4. For PID: (Fever)
5. For Candidal infection: (curd-like discharge)
a. Do you have a Hx of DM?
b. Have you been using steroids recently?
Exam
1. HEENT
2. Abdominal Exam
Investigations

2. Discharge exam and Culture
4. Blood Culture
5. U/S Abdomen
6. Pap smear
Dyspareunia
mnemonic:
Differential Diagnosis: PV3 A2CE
Vagina:Atrophic
Vaginitis,Vaginismus,
Vaginismus,Vulvodynia
Vulvodynia
Cervix: Cervicitis
Cervix: Cervicitis
Uterus:Endometriosis,
Uterus: Endometriosis,Pelvic
PelvicTumor
Tumor
Other:Abuse
Other: Abuse
Questions
Insert transitional statement for Gynae/ Obs questions.
1. When was your LMP?

2. When was your first Menstrual period (Menarche)?
3. Do you feel Pain during intercourse or defecation?
4. Are your cycles Regular?
5. How many Tampons/Pads do you use on a heavy day?
6. Have you noticed Crampy pain during menses?
7. Have you noticed any Vaginal discharge?
8. Have you noticed any Spotting in between periods?
9. Are you Pregnant?
10. Have you ever had Abortions?
11. When was your Last Pap smear?
12. Have you noticed any change in your sexual Desire?
13. Have you ever been Abused?
14. Do you have any Conflict with your partner/husband? If yes, then SAFE-GARD
a. Do you feel Safe at home?
b. Are you AFraid of _________?
c. Do you have any Emergency (Exit) plan?
d. Do you have a Gun at home?
e. Is your __________ Alcoholic?
f. How is the Relationship of your ___________ with others?
g. Do you feel Depressed (Suicidal ideation)?
Exam
1. HEENT
2. GIT and CVS Exam
Investigations
1. Rectal & Pelvic Exam.

3. Stain and Culture of Discharge.
4. U/S Abdomen & CT scan Abdomen
5. Laparoscopy
Sleep Problems/Insomnia
 What do you do before you go to bed?

 Have you noticed any trouble falling asleep?
 Do you have night time awakenings?
 What time do you wake up in the morning?
 Do you feel sleepy or take naps during the days?
If the patient has true insomnia judging from the above questions, then ask OFDPAA of this complaint
and then use the following mnemonic.
Differential Diagnosis: SADICCH
Brain:
Brain:Stress,
Stress,Circadian
CircadianRhythm
Rhythm
Mouth:
Mouth:Drugs,
Drugs,Caffeine
Caffeine
Neck:
Neck:Hyperthyroidism,
Hyperthyroidism,OSA OSA
Questions
1. For Stress/Adjustment:
2. For OSA:
a. Do you snore at night? Or has someone told you?
b. Do you feel restless at night? Or has someone told you?
3. For Illicit Drugs:
4. For Caffeine:
b. Do you take tea/Coffee/energy drinks before going to bed?
5. For Circadian Rhythm problems: If sleep duration is adequate then
a. Advanced Sleep Syndrome; sleeps at 2:00 am
b. Delayed Sleep Syndrome; sleeps at 6:00 pm
c. Jet Lag; Travel Hx
Exam
1. HEENT
Investigations

2. TSH, T3 & T4
3. Urine Toxicology screen.
4. Cortisol levels.
Closure
Mr./Ms. XYZ thank you for your patience and cooperation. Depending on the history and PE, I am
since you are in safe hands. Meanwhile, I am KUO and would advise you to avoid caffeinated beverages
3-4 hours before going to bed, go to your bed only to sleep, make sure your room is dark and curtains
are drawn down, and avoid watching television or reading before going to bed. Eat a healthy and
balanced diet high in fruits and vegetables, low in salt, and caffeinated beverages. Do regular exercise,
follow a healthy lifestyle, and keep stress at a minimum.
Weight Gain
Differential Diagnosis: DPT Qs in FCPS
Endocrine: Hypothyroidism, Pregnancy, PCOS, Cushing

Endorcine: Hypothyroidism, Pregnancy, PCOS, Cushing
CNS: Familial, Depression
CNS: Familial, Depression
Other: Smoking Cessation
Other: Smoking Cessation
Questions
How much weight have you gained? Over how much time? Intentional or unintentional?

2. For Pregnancy: (LMP + Morning sickness)
3. For HypoThyroidism: (Temp intolerance, skin changes, bowel habits)
4. For Familial tendency:
a. Any family Hx of obesity?
5. For Cushing’s:
a. Have you noticed any stria on your body?
6. For PCOS:
a. Have you noticed any excessive hair growth recently?
b. Have you noticed any abnormal pigmentation of the body?
7. For Smoking Cessation:
Exam

2. GIT Exam
Investigations

2. TSH, T3 & T4
3. Glucose, Cholesterol, Triglyceride levels.
4. Cortisol levels.
5. Urine β-HCG.
Weight Loss
Differential Diagnosis: HAMID MD
With Increased Appetite Hyperthyroidism, Depression (Atypical), Malabsorption, Diabetes

With Decreased Appetite Anorexia, Malignancy, Infection, Depression (Typical)
Questions
How much weight have you lost? Over how much time? Intentional or unintentional?
1. For Hyperthyroidism: (Temp intolerance, tremors, Palpitations, Bowel habits)
2. For Anorexia Nervosa: (weight/appetite changes)
a. How do you feel about this problem?
b. How do you feel about your physical appearance?
3. For Malignancy: (Fatigue, smoking, Alcoholic)
4. For Infections:
a. T.B: PENT Questions
b. HIV: Ill contact, low-grade fever, IV drug abuse.
5. For Depression (Mood + SIGECAPS)
6. For Drugs: (Laxatives, Thyroxine)
7. For Malabsorption:
a. Are your stools difficult to flush?
b. Are your stools foul smelling?
c. Have you noticed a sense of incomplete evacuation after passing stools?
8. For Diabetes Mellitus: (Excessive thirst, urinary frequency)
Exam

2. GIT Exam
Investigations

2. TSH, T3 & T4
3. PCR or ELISA for HIV
4. Sputum for AFB
5. Urinalysis
6. CXR
Tremors
Differential Diagnosis: In PC we learned that PE has high LDH
At Activity Cerebellar, Liver Disease

At Rest Parkinsonism
At Both Essential, Physiological, Hyperthyroidism, Drugs
Questions
Are the tremors at rest?
1. For Physiological:
a. Is the tremor associated with any event?
2. For Cerebellar Disease:
a. Have you noticed any abnormal eye movements?
b. Have you noticed any problems with movements/complex movements?
3. For Parkinsonism:
a. Have you noticed any slowing of your movement?
b. Have you noticed any stiffness of body?
c. Have you noticed any changes in your writing?
4. For Essential Tremors: (Family Hx, Relived by Alcohol or Propranolol)
5. For Liver Disease:
a. Have you noticed any distension of your belly?
b. Have you noticed enlargement of breasts?
c. Have you noticed any change in your skin?
6. For Drugs: (caffeine, nicotine, β-agonists, TCA, Lithium, Valproate etc.)
Exam

2. CNS Exam, Romberg’s
3. GIT exam for liver disease
Investigations

2. TSH, T3 & T4
3. ALT/AST/ALP/Bilirubin
Muscle Weakness
Differential Diagnosis: Funny PM has PTSD
Stiffness Muscle Neuro Drugs Electrolytes
Fibromyalgia, PMR, TIA/Stroke,

Anti-Dopamine &
With Stiffness Muscle Strain, Parkinsonism,
Anti-Psychotics
Myotonic Dystrophy Multiple Sclerosis
Polymyositis, GBS, Myasthenia Hypokalemia.
Without Stiffness Steroids, Statins
Dermatomyositis Gravis HyperThyroidism.
Questions
With stiffness:
1. For Fibromyalgia: (Sleep problems or depressions)

a. Have you noticed any tender points in the body?
2. For PMR:
a. Have you noticed any difficulty standing from sitting position?
b. Have you noticed any changes in vision or headaches?
3. For Muscle Strain (Trauma):
4. For Myotonic Dystrophy: (Family Hx)
a. Have you noticed any hair loss from the head?
b. Have you noticed any difficulty releasing objects?
5. For TIA/Stroke: (WNT, Gait, Vision)
6. For Parkinsonism:
a. Have you noticed any slowing of your movement?
b. Have you noticed any stiffness of body?
c. Have you noticed any changes in your writing?
7. For Multiple Sclerosis: (Female, Age)
a. Have you noticed any change in your vision?
8. For Drugs: (Anti-Dopamine & Anti-Psychotics).
Without Stiffness:
1. For Polymyositis:
a. Have you noticed any difficulty combing head or standing from sitting position
2. For Dermatomyositis:
a. Have you noticed any rash on your body?
3. For GBS:
a. Do you have any Hx of Diarrhea or sore throat?
b. How did the weakness progress?
4. For Myasthenia Gravis:
b. Have you noticed any problem in vision or double vision?
5. For Drugs( Steroids, Statins.)
6. For Electrolytes; (Hypokalemia)
a. Do you have a recent Hx of Diarrhea?
7. For HyperThyroidism (Temp intolerance, Bowel movement)
Exam

2. CNS Exam
3. Extremities exam
Investigations

2. TSH, T3 & T4
3. Nerve Conduction study
4. MRI Brain
5. ANA, Anti-Ro, Anti-LA
Hallucinations
 Can you please tell me more about that?

 Do you see, hear or feel things?
 What do they tell you?
 Do they control you?
 Do they tell you to harm yourself or others?
 Does anyone else experiences that or are you the only one?
 Has it affected your daily life performance?
If the patient has true insomnia judging from the above questions, then ask OFDPAA of this complaint
and then use the following mnemonic.
Differential Diagnosis:
Auditory Hallucination Brief Psychotic disorder, Schizophreniform, Schizophrenia.

Visual Hallucinations Tumor, Substance Abuse, Seizures, Delirium and Dementia.
Tactile & Gustatory Hallucinations Cocaine, Alcohol withdrawal.
Secondary to Medical disorder Parathyroidism, Narcolepsy, Postpartum Psychosis
Questions
For Auditory Hallucination:
1. For Brief Psychotic disorder: (stress, sleep, decreased functioning)

2. For Schizophreniform & Schizophrenia: (ideas of reference, classify according to time)
For Visual Hallucinations:
1. For Bain Tumor: (weight loss, headache)

2. For Substance Abuse:
3. For Seizures:
4. For Delirium and Dementia: (reversible Vs. Irreversible)
For Tactile & Gustatory Hallucinations:
1. For Cocaine withdrawal:

2. For Alcohol withdrawal:
For Secondary to Medical disorder:
1. For Parathyroidism:
a. Have you noticed any change in your bowel habits?
b. Have you noticed any pain in the belly?
c. Do you have a Hx of kidney stones?
2. For Narcolepsy:
a. Have you noticed any problems with sleep?
3. For Postpartum Psychosis:
a. When was your LMP?
Exam
1. MMSE
2. CNS Exam
Investigations

2. Urine Toxicology screen.
Jaw Pain
After Introduction ask OFDPLIQRAA of Jaw pain then ask following questions: WRSSWNT of the jaw.
 Have you noticed any warmth of your jaw?
 Any redness?
 Any swelling?
 Any stiffness?
 Any weakness, numbness, or tingling on your jaw?
After asking these questions, now ask the following DDs:
Differential Diagnosis: MTB DANDA
MI Have you noticed any chest pain?

Any racing of your heart?
Any sweating?
Trauma Have you experienced any trauma to your jaw?
Bruxism Do you grind your teeth while sleeping?
Or has someone else told you?
Dysfunction Have you noticed any popping sounds from your jaw?
Temporal Arteritis Do you feel pain while touching your temple area?
Trigeminal Neuralgia Have you noticed any electrical sensation in your face or around your jaw?
Dental Have you noticed any a toothache?
Abuse How is your relation with your spouse/husband?
After DDS part, ask for any associated injuries (like wrist injury). Remove any bandage and observe the injury like,
Why are you wearing this bandage/ribbon? Can you please show it to me?
Can you tell me what this is?
Then ask:
 Are there any bruises anywhere else on your body?
 Do you have a history of easy bruising?
 Is there anyone in your family with a tendency of easy bruising?
Thank you so much for sharing this with me. Please wear your bandage/ribbon again.
How is your relationship with you, spouse/boyfriend? (if patient tells you about domestic abuse, then apply SAFEGARD
here)
After that apply PAMHUGFOSSS. During sexual history, ask are you sexually active? With whom may I ask? Do you have
any kids? How is your relationship with your spouse/boyfriend?
After PAMHUGFOSS, summarize the case and do the examination.
Examination
Inspection of the jaw

Palpation of the jaw
Range of Movement (ROM)
 Can you please open your mouth for me and sideways?
If the patient still hasn’t disclosed about domestic abuse and there is no significant finding in the history or
PAMHUGFOSSS, use the following transitional sentences:
Well thank you so much Ms. XYZ for sharing details with me, but depending on the history and PE your presentation
doesn’t match with any diagnosed medical illness, but I have seen many cases with a similar presentation in my career
who were victims of abuse. Initially, they were reluctant to tell me, but when the told me they got very good help. Ms.
XYZ this might not be the case with you, but for the sake of confirmation I am going to ask a few questions regarding
your relationship with your spouse/boyfriend and these may seem awkward, but let me assure you these are very
important for making the diagnoses and these will not be revealed to anyone including your spouse/boyfriend. Can I ask
them, please?
C/Q: Doctor why do you think that I am a victim of abuse?

You: Thank you very much for sharing your concern. I am thinking this as a possibility because I have ruled out all the
medical causes of your jaw pain. Moreover, your late medical attention and pattern of injury of your wrist make me
more suspicious and the third reason is my clinical experience. Is that alright?
So Ms. XYZ how is your relationship with your spouse/boyfriend?

(Now patient will tell you the story of abuse)
Ask SAFEGARD questions (You can use SAFEGARD whenever patient gives you history of abuse either after DD part or in
PAMHUGFOSSS)
S: Do you feel safe at home?

AF: Are you afraid of your spouse/boyfriend?
E: Do you have any emergency/exit plan?
G: Do you have guns at home?
A: Is your spouse/boyfriend an alcoholic?
R: How is the relationship with your spouse/boyfriend with others/children?
D: How is your mood? Have you ever tried to hurt yourself?
If the patient gives depression/low mood and/or anhedonia, then use SIGECAPS.
Closure
Thank you so much sharing all this information me. Depending on the history and examination, I am thinking several
possibilities for your current complaint that your jaw pain might be related either damage to the supporting structures
of the jaw or bone fracture, but I am not sure right now. For this, I will have to run some test which will include some
blood workup like complete blood count or some imaging studies of your jaw like X-ray and MRI if needed. When the
results will be back we will sit together and discuss the further management plan and you don’t need to worry, you are
in safe hands.
Meanwhile, I am KUO and my nurse is going to give you some pain medication and cold compresses for your swelling
and I would suggest you eat soft foods and speak less because it can increase your pain. Miss XYZ, I must tell you that
abuse doesn’t end on its own. You must stand against it, you can involve your family members as well as your parents.
In this regard, you can seek my help and I’m going to give you my number as well as my email. You can contact me by
any means and again I would suggest you that face it, don’t be shy and don’t be weak. You must deal it on your own and
I am here to help you as much as I can. There are some social groups you can join and you can call 911 in the case of
emergency. While regarding the protection of your child it’s my legal and medical duty to report it to Child Protection
services.
C/Q: Doctor I want to live with my spouse/boyfriend?
You: I respect your decisions and the final decision will be yours but let me tell you that abuse does not end on its own.
You must stand against it. In this regard, you can involve your family members as well as your friends too for your social
and moral support as well. And I am sorry that you are going through this pain but again. At the end, I tell you that you
must do it on your own. Is there anything I can do for your comfort, Miss Jennifer?
ADHD
Mr. XYZ it looks like you are in some distress. I assure you I am here to help you and only you can
guide me regarding your problems, please come sit down so that I can help you in a better way and
help solve the issue that you are experiencing.
Are you comfortable? Very good!
After the introduction, ask OFDPAA.
O When did your troubles first start? “onset”

F Do you get periods of calmness in b/w these episodes? (frequency)
D For how long, you are having this problem?
P Do you constantly experience such difficulty or does it happen on certain occasions / is there any
the specific event associated with it?
A Anything that helps you calm down?
A Anything that aggravates your condition?
Questions
Distracted: Do you get easily distracted by tv/people/voices?
Fidgety : Do you have any trouble stand still?

Interrupt: Does anyone ever told you that you interrupt others while they are
talking?
Active: Do you feel overly active as if driven by a motor?
Organization: Do you have trouble performing organized activities?

Turn: Do you have trouble waiting for your turn?
Childhood: Did you have similar complaints in the past?
Misplace: Do you misplace your things a lot?
Homework: Did you notice difficulty finishing your home tasks?
C/Q: I really appreciate that you are looking up to the expectations of your parents, but don’t feel bad
as you are trying your best. I assure you I will do all I can to reach the bottom of your diagnosis.
Closure
It may be due to a chemical imbalance in your brain/due to substance abuse but I need to run some tests like imaging
studies like CT of your brain, urine test once I get the results I’ll be able to guide you in a better way. Meanwhile, I will
advise you to avoid using any electronic devices while you are studying (like cell/tablets). Keep up a schedule of things
that you must do, make a diary and note down your schedule, take breaks in between your studies, organize your
belongings at your home and workplace so that you don’t misplace them. We have got a wonderful team with us and
we are going to do everything that we can to help you in a better way.
Hypomania
(Part of bipolar disorder)
Patient hyperactive moving around in the room.
Doorway information: Not feeling like himself
I understand Mr. XYZ that you are in some distress, I can only imagine what’s going on with you. It is
only you who can tell me what is exactly wrong. Let me assure you that I am here to help you out, but only if you sit
down and tell me what’s going on with you.
Allow me to introduce myself, my name is Dr.________ and I am your physician today. Are you comfortable here? May
I ask some questions?
 Can you please elaborate on your situation?

 How long has it been going on?
 Is it getting any better/worse with time?
 Does it happen occasionally/often?
 Is it associated w/ some special situation/condition?
 Anything that you have noticed may make you feel better/help you get back on the track?
Ask sleep questions: If sleep is ok & patient feels fresh on waking, then ask mania questions.
Ask activities & daily lifestyle.
For Diagnosis: DIG FAST
Questions
Difficulty in concentrating
Impulsive: Have you taken any decision without thinking of
Consequences?
Grandiosity: What do you think about yourself? Do you have any
special abilities/do they convey some kind of message?
Flight of ideas: Have you noticed too many ideas running in your mind?
Active: Do you feel overly active?
Sleep:
Sexual activity: Do you feel sexually overactive?
Closure
Mr. XYZ your current complaint may be because of chemical imbalance in your brain or it can be due to substance
abuse for which I need to run some tests like imaging study of your brain and urine drug screen. Meanwhile, I will
advise you to always keep a healthy lifestyle, eat healthy, sleep healthy and exercise regularly, and avoid any nighttime
shifts at job or night flights. If you want I can put you in contact with social support groups where many people with
similar conditions have benefited from & if you feel any problem, feel free to contact me. Is there any question that you
want to ask? Have I met all your concerns? Goodbye and have a nice day.
Night Sweats
Differential Diagnosis: THe LMC P2H2
Endorine: Hyperthyroidism, Hypoglycemia, Menopause

Cancer: Lymphoma, Carcinoid, Pheochromocytoma
Infection: TB, HIV, IM
Gynae: Premature Ovarian Failue, Menupause
Questions
TB PENT Qs. (PPD, exposure, night sweats, travel ), living conditions, cough
Bloody sputum, weight loss.
HIV Lumps & bumps, promiscuous, IV drug abuser, sore throat, weight loss,
Diarrhea (watery)
Lymphoma: Belly distension/fullness, weight/appetite loss, lumps & bumps.
Menopause: Episodic sudden hot flushes, no HRT, dryness/itching, dyspareunia
Carcinoid: Episodic flushes, watery diarrhea, wheeze, palpitations
Pheochromocytoma: Episodic headache with HTN, palpitation, tremors.
Premature ovarian: Early age menopause
Failure
Hyperthyroidism: Skin changes, palpitations, sweating, tremors, proptosis,
Heat intolerance.
Hypoglycemia: Hx of DM, skipped meals, doses/med changes.
Ask about profession first (may present with a history of close contact with prisoners).
Examination
1. HEENT
2. Chest
3. GIT
Investigation
1. Rectal and Pelvic Exam
2. CXR and Sputum analysis
3. Western blot for HIV
4. T3, T4, TSH
5. Blood Sugar Level
6. FSH, LH
Closure
Mr./Ms. XYZ thank you for your patience and cooperation. Depending on the history and PE, I am considering a
number of possibilities of your current complaint that it might be due to ______________, but I am not sure right now.
For this, I will have to run some tests that will include some blood work up like complete blood count, sputum
examination, and some imaging studies like X-ray and CT scan of your chest. When the results are available, we will sit
together and discuss the further management plan and you don’t need to worry since you are in safe hands.
Meanwhile, I am KUO and provide adequate hydration and will advise you to always wear a mask, try avoiding contact
with people who have infections and get yourself vaccinated. Exercise regularly, follow a healthy lifestyle and keep
stress at a minimum.
Constipation
Differential Diagnosis: CHID5S
Local: Colon CA, Diverticulitis, IBS, Hard stool (Dehydration)

Endorine: Hypothyroid, DM
Other: Diet, Drugs, Depression
Questions
Colon CA Appetite Change. Missed Colonoscopy, Belly Pain, Change in stool caliber
Hypothyroid Cold intolerance, skin change edema, Weight Gain
IBS Belly Pain, Alternate diarrhea and constipation, Stress-induced, Pain relieved
w/ defecation
Diet Low fiber diet
DM Polyuria, polydipsia, polyphagia, gastroparesis
Depression/Stress Mood changes + SIGECAPS
Drugs CCB, iron tablets, anti-depressants, narcotics, tums, marijuana, opioids
Diverticulitis Belly pain, low fiber diet, blood in stools, fever, LLQ pain, junk food
Dehydration Bowel changes, drugs, blood loss
Examination
1. HEENT
2. Abdominal Examination
3. Thyroid Exam
Investigation
1. Rectal & pelvic

2. FOBT
3. Colonoscopy
4. Urine toxicology
5. Becks depression inventory
6. Hba1c
7. Blood sugar levels
Dysphagia
After Introduction, ask the following question:
 Do you have problems swallowing solid, liquids, or both?

 Do you have difficulty swallowing during initiation, middle, or end?
 Have you experienced pain during swallowing?
 Do you have a craving for ice/clay?
 Ask about the problem is with solid /liquid foods/ both?
After asking these question, ask OFDPAA of the complaint and then use the following DDs.
Esophagitis: Pain on swallowing + fever

Pharyngitis (ear/eye/nose discharge, ear fullness)
HIV (lumps & bumps, diarrhea, IVDA, weight loss, unsafe sex.
Gerd Burning in chest, metallic taste of mouth
Diffuse esophageal
Spasm Dysphagia + sudden epi of chest pain relieved by rest
Esophageal ca Weight/appetite changes, smoking/EtOH, pickled food
Zenker Bad breath + late night regurgitation of food
Achalasia South America visit (Trypanosoma?)
Plummer-Vinson Fe Deficiency anemia. SOB on exertion, Skin color change, Taste Change
Syn
Myasthenia Double vision, weakness throughout day
Mitral stenosis Rheumatic fever history, leg swelling
Stricture Accidental acid/alkali/too hot beverages
Scleroderma Crest syndrome (sclerosis thickened fingers, visible pulses)
Examination
1. HEENT (pulses, skin, nail color)

2. GIT Exam
3. CVS Exam
Investigation
1. Barium swallow
2. Esophageal manometry
3. Upper GIT endoscopy w/ biopsy
4. CXR, X-ray neck, video fluoroscopy
5. CT/MRI/PET
6. Iron studies (TIBC, Fe, ferritin)
7. CBC w/ diff, ESR, electrolytes
8. ELISA, western blot (HIV)
9. Anti-centromere Ab
10. Anti-scl-70 Ab
Toe discoloration
OFDPAAA, TRRMP BC
Trauma Have you had any recent trauma?

Raynaud’s Have you noticed any tightening of your skin or problems with swallowing?
(with crest syndrome & scleroderma)
(female, transient vision loss, butterfly rash)
Recent bypass/angiography
Microvascular disease due to HTN/DM /smoking/hypercholesterolemia
Polycythemia
Burgers Do you smoke?
Cold Have you had any recent exposure to cold?
Investigations
 Doppler U/S
 Ankle-brachial index (ABI)
 Angiogram legs
 Blood sugar levels, HbA1c, hba1c
 Serum cholesterol, LDL, HDL
 EKG, Echocardiogram
 Chest X-ray
Closure
Mr./Ms. XYZ thank you for your patience and cooperation. Depending on the history and PE, I am
considering a number of possibilities of your current complaint that it might be due to ______________, but
I am not sure right now. For this, I will have to run some tests that will include some blood work up like a
complete blood count and lipid levels, and some imaging studies of your feet like an angiogram and U/S.
When the results are available, we will sit together and discuss the further management plan and you don’t
need to worry since you are in safe hands. Meanwhile, I am KUO and would advise you to wear gloves and
comfortable and dry shoes, take your pills regularly, maintain good control of your blood pressure and
sugars, and quit smoking. Exercise regularly, follow a healthy lifestyle and keep stress at a minimum.
Pediatric
Case
Prerequisites for Pediatric cases:
 Can you please tell the name and age of the child?
 Are you legal guardian of the child?
 Do you need any help with your ____________?
 Instead of PAM HUG FOSS for adults, replace PAM F BIND.
 Birth Hx:
o Was there any complication during pregnancy?
o Did you take iron/multivitamins during pregnancy?
o Did you smoke or drink alcohol during pregnancy?
o Was the baby delivered at term?
o Was the delivery normal?
o What was the mode of delivery?
o Any complications during or after pregnancy?
x Immunization:
o What is the immunization status of the baby? Can you please show me?
o If on the phone, please bring you immunization card to the hospital?
 Nutrition:
o How do you feed your child? (breast/formula)
o When was solid food added to the diet?
o What is the diet now?
x Development Hx:
o When did he/she start smiling?
o When did he/she start to sit?
o When did he/she start to walk?
Fever
Differential Diagnosis: VO MUL GU
Viral illness, Otitis Media, Meningitis, URI, LRI, Gastroenteritis, UTI.
What do you mean by “burning up”?

For how long? Continuous or intermittent? High grade or low grade? What is the reading? Oral
or rectal?
How is the child look? (Lethargic, irritated or playful)
1. For Viral illness:
a. Have you noticed any rash on the body?
b. Have you noticed any swelling of the body?
2. For Otitis Media:
a. Does he/she pull the ear?
b. Have you noticed runny nose or redness of eyes?
c. Have you noticed any discharge from the ear? If yes, then ABCO
3. For Meningitis/Encephalitis:
a. Have you noticed any stiffness in the neck?
b. Did he/she lose consciousness?
c. Have you noticed any shaky movements?
d. Have you noticed bulging of fontanels?
4. For URI:
a. Has the child come in contact with anybody with similar complaints? (daycare, siblings)
b. Croup:
i. Have you noticed any a cough?
ii. Have you noticed any sound accompanying? (stridor)
c. Epiglottitis:
i. Have you noticed any difficulty swallowing?
ii. Have you noticed drooling of saliva?
5. For LRI: (Bronchiolitis)
a. Have you noticed any difficulty breathing?
b. Have you noticed fast breathing or abnormal sounds with breathing?
6. For Gastroenteritis:
a. Have you noticed any change in bowel habits?
b. Have you noticed nausea or vomiting?
c. Have you noticed any distension of the belly?
d. Do you have to use more diapers than usual?
7. For UTI:
a. Have you noticed any change in urinary habits?
b. Does the baby cry while urinating?
Exam
1. HEENT
2. CVS Exam.
Investigations

2. CXR
3. Blood Culture
5. Urinalysis
Seizures
Differential Diagnosis: FM TE
Febrile, Meningitis, Trauma/hemorrhage, Hypo/Hypernatremia.
Please tell me more about that? Describe the event in

detail? What was the child doing before that?
Have you noticed any LOC? Tongue biting or frothing? Passed urine or stools without knowledge?
What happened after the episode?
1. For Febrile seizure: (Fever, Family Hx)
a. Do you have a Hx of recent illness?
2. For Meningitis:
a. Have you noticed any stiffness in the neck?
b. Did he/she lose consciousness?
c. Have you noticed any shaky movements?
d. Have you noticed bulging of fontanels?
3. For Trauma/hemorrhage:
4. For Hypo/Hypernatremia:
b. Have you noticed nausea or vomiting?
c. Have you diluted the formula feed?
Exam
1. HEENT
2. CVS Exam.
Investigations

2. CXR
4. CT scan brain
5. Urinalysis
Diarrhea
Differential Diagnosis: Infection, Malabsorption, Intussusception, Overfeeding
1. For Infection:
a. Do you have to use more diapers than usual?
b. Have you noticed any dryness of mouth or tongue?
c. Have you noticed any dryness of skin?
d. Have you noticed sunken eyes?
2. For Malabsorption:
a. Have you noticed any abnormal smell from stools?
3. For Intussception:
a. Have you noticed crying spells or episodes relieved by bending?
4. For Overfeeding:
a. How much and how frequently do you feed the child?
Exam
1. HEENT
2. GIT Exam.
Investigations

2. Stool examination
Cough
Differential Diagnosis: LPC FERA.
Laryngitis, Pertussis, Croup, Foreign Body, Epiglottitis, Retropharyngeal Abscess, Asthma
Can you please tell me more about it? How will you describe a cough?
1. For Laryngitis:
a. Have you noticed any change in the voice?
2. For Pertussis:
a. Have you noticed a runny nose or watering from eyes before a cough appeared?
b. Have you noticed any additional sound along with a cough?
c. Did the baby throw up?
3. For Croup:
a. Have you noticed any a cough?
b. Have you noticed any sound accompanying? (stridor)
4. For Foreign Body:
a. What was he doing when a cough started?
5. For Epiglottitis:
a. Have you noticed any difficulty swallowing?
b. Have you noticed drooling of saliva?
6. For Retropharyngeal Abscess: (High-grade fever + No stridor)
a. Have you noticed any drooling of the saliva?
7. For Asthma:
a. Does the baby have any allergies?
b. Have you noticed any relationship to the timings of the day?
Exam
1. HEENT
2. CVS and Pulmonary Exam.
Investigations

2. X-Ray neck
3. CXR
4. Blood Culture
Picky Eater
Differential Diagnosis: OHIO ATA.

Organic disorder, Habitual Eating Disorder, Iron Deficiency, Oppositional Defiant disorder, Autism,
HypoThyroidism, Adjustment disorder.
OFD Questions
How is the child growing? Did he gain any weight? Milestones achieved?
1. For Organic disorder:
b. Have you noticed any blood in stools?
c. Have you noticed crying discomfort on passing stools?
2. For Habitual Eating Disorder:
a. Do you follow a set schedule of meals?
b. Does he drink a lot of high-calorie drinks?
3. For Iron Deficiency:
a. Have you noticed a change in skin color?
b. Have you noticed a bleeding from any site?
4. For Oppositional Defiant disorder:
a. How is his behavior towards others?
5. For Autism:
a. Does the child have problems playing with others?
6. For HypoThyroidism: (temp intolerance)
a. Have you noticed a change in bowel habits?
7. For Adjustment disorder:
a. Have you recently moved?
b. Has the child suffered any trauma recently?
Exam
1. HEENT
2. GIT Exam.
Investigations

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USMLE STEP 2 Clinical

Skills Basic CS Notes

1. Greeting (Hello/Hi, Mr./Miss. XYZ + Good morning/evening)

You: Mr./Miss XYZ?

O: How did this start? S-sudden, G-gradual

(In MSK-musculoskeletal cases, associated features are WRSS WNT

DD1  In ER cases, on entering when patient is in immediate distress, say:

PAMHUGSFOSSS is divided into six parts.

1. Past Medical Health = Any Chronic Illness + Allergy + Medication + Hospitalization

1. Have you experienced any similar complaints in the past?

If Answer is yes, then ask following questions.

3. Are you allergic to anything?

If SP says NO, then say like any foods or medications?

4. Have you had any hospitalizations in the (recent) past? Yes/No.

If it is the Non-Gynecological case, then ask the following question?

 L: When was your last menstrual period?

1. HPI = OFDP(LIQR)AAA + DDs Positives and denials

For writing labs,

o Enjoy the rest of your day.

Auscultation…heart & carotid sounds + lung sounds

The full MMSE is used in following cases:

While only orientation part is used in following cases:

Vital (Only Abnormal Ones): ____________________________________________________________

P HTN +/- Dr +/- M+/- C+/- (If age >50)

F Mother  Orthostatic Vitals

( + = Yes, - = No, +/- = Occasional)

Dr. Furqan Haider Syed

Blood in Stools ..........................................................................................................................................

Lower Abdominal Pain ..............................................................................................................................

Testicular Pain ...........................................................................................................................................

Knee Pain ................................................................................................................................................

Back Pain .................................................................................................................................................

Heel Pain .................................................................................................................................................

Hip Pain ...................................................................................................................................................

Calf Pain ..................................................................................................................................................

Chest pain ...............................................................................................................................................

Sore Throat .............................................................................................................................................

Urinary Incontinence ..............................................................................................................................

DM and HTN follow- up ..........................................................................................................................

Pre-Employment Exam ...........................................................................................................................

Hearing Loss ............................................................................................................................................

Dizziness (LOC) ........................................................................................................................................

Menstrual Irregularities ..........................................................................................................................

Post-Menopausal Bleeding .....................................................................................................................

Vaginal Discharge ....................................................................................................................................

Sleep Problems/Insomnia .......................................................................................................................

Weight Gain ............................................................................................................................................

Weight Loss .............................................................................................................................................

Muscle Weakness ...................................................................................................................................

Jaw Pain .................................................................................................................................................

Picky Eater ...........................................................................................................................................

8. Any Change in your urine color or stool color?

1. Rectal & Pelvic Exam

Differential Diagnosis: Watery, Bloody, Malabsorption

For Watery Diarrhea:

For Bloody Diarrhea:

1. For Pancreatitis: (Alcoholic)

1. HEENT + Thyroid exam