FOR THE IMGs

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USMLE STEP 2 CS

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A GUIDE THAT CONTAINS ALL THAT YOU NEED TO PASS THE CS EXAM.

GENERAL HISTORY TAKING AND PHYSICAL EXAMINATION THAT CAN BE APPLIED TO ALMOST ALL CASES SPARING LONG HOURS OF STUDYING EACH CASE ALONE.

HOW TO PERFORM A COMPLETE AND RAPID CLOSURE AND COUNCELING.

USEFULL STUDY TIPS FROM STUDENTS WHO PASSED THE EXAM.

USEFULL EXAM EXPERIENCE FROM EXAM PASSERS.

USEFULL STRATEGIES FOR CHALLENGING PATIENTS WHATEVER THE CHALLENGING QUESTIONS ARE.

WHAT TO SAY AND WHAT NOT TO SAY DURING THE ENCOUNTER.

REVIEW REPORTS ABOUT THE AVAILABLE CS BOOKS AND VIDEOS.

CD INCLUDED CONTAINING PHYSICAL EXAMINATION VIDEOS.

FIRST EDITION

GOLD STANDARD

1

Preface

The USMLE STEP 2 CS is a source of anxiety and concerns among all IMG’s and that what inspired me to write this book. Being a USMLE step 1 and 2 passer with scores of 99 , I felt while studying the CS that I could make It a lot easier for a lot of fellow IMG’s who are not used to taking history and doing physical examination both in English and by the American school of practice.

Through the help of a lot of fellow residents, attendings and friends I present to you this book that will make a process that may be painful and difficult feel a lot better and easier.

This GOLD STANDARD includes:

A GUIDE THAT CONTAINS ALL THAT YOU NEED TO PASS THE CS EXAM.

GENERAL HISTORY TAKING AND PHYSICAL EXAMINATION THAT CAN BE APPLIED TO ALMOST ALL CASES SPARING LONG HOURS OF STUDYING EACH CASE ALONE.

EVEN IF YOU DONT KNOW THE CASE FOLLOW THESE STEPS AND YOU WILL PASS.

USEFULL STUDY TIPS FROM STUDENTS WHO PASSED THE EXAM.

USEFULL EXAM EXPERIENCE FROM EXAM PASSERS.

USEFULL STRATEGIES FOR CHALLENGING PATIENTS WHATEVER THE CHALLENGING QUESTIONS ARE.

WHAT TO SAY AND WHAT NOT TO SAY DURING THE ENCOUNTER.

HOW TO PERFORM A COMPLETE AND RAPID CLOSURE.

USEFUL WEBSITES AND BOOKS FOR THE EXAM.

Aly H. Abayazeed

2

CONTENTS

The exam …………………………………………………………………………….4

Study tips ………………………………………………………………………….….5

Chapter 1History …….…………………………………………………………………………6

Chapter 2Physical examination………………………………………………………………...18

Chapter 3Patient notes………………………………………………………………………….28

Chapter 4Differential diagnosis Of important presentations…………………………………………..….……………34

Chapter 5Closure and counseling………………………………………………………………44

3

The Exam

The exam is in the form of 11 or 12 cases in which you are requested to take history and do physical exam on each case in 15 minutes period and then to write the patient notes including the history , physical exam , differential and workup in 10 minutes.

You are allowed only to have a white coat, a stethoscope and what you will eat during the breaks into the exam area.

The day starts at 8am for morning session and 3pm for the afternoon session so it is better to be at the exam center at 7:30 and 2:30 respectively.

The day start by an introduction about the exam and demonstration of the tools that is used in the exam rooms during the encounter, please feel free to use all the equipments during the demonstration so you can feel comfortable while using them during the encounters.

At 9am and 3pm the sessions begins with every doctor standing in front of an examination room with the patients notes written on the door, you are not allowed to see the patient notes until you hear the announcement that you can start the encounter then you knock and enter the room.

The encounter last for 15 minutes during which you have to take a focused history and do a focused physical exam, then after leaving the room you will be given 10 minutes to write the patient notes (history , physical , differential and workup)

Of the 11 or 12 cases only 10 cases will be marked and the marks will be determined by 3 components: Integrated clinical encounter (ICE) which contains data gathering and patient notes, Communication/interpersonal skills (CIS), Spoken English proficiency (SEP).The score that you receive for the CS will be either “PASS” or “FAIL”.

4

STUDY TIPS

1- Practicing the cases is the most important single strategy to pass the exam. The time constraints during the encounter and writing of patient notes makes practice so important so you do not have to think about every question and examination technique and note to write, all will become a routine that you will feel more confident during the encounter and spare your mind for better communication with the SP the area that most IMG’s have the biggest problem at.

2- Studying of the mental check list of each case that you practice is very important so not to miss a question in the history taking or a special examination for one of the differential diagnosis.

3- Study groups where you can be the doctor and the SP in different cases will put you very close to the real exam and will uncover all your weakness points so you can work on before the real thing.

4- Dividing the history into 2 main sections: the HPI (history of present illness) and the PAM-HS-FOSS. Discussed later in details in the how to take a history.

5- Examination is divided into case related system focused exam, heart and lung auscultation and related general exam. Discussed later in details in how to make the physical exam.

6- Closure and counseling needs good practice for what to say and how to say it, through several study groups that I have been to, I found this to be a challenge to IMG’s and this will be greatly improved after you read the section on how to do closure and counseling.

7- Patient notes writing are better written from down-up. Discussed later in details in how to write patient notes.

Remember:

The more you practice the better you will gradually be.

English is one third of the exam so practice the language well.

Communication skills and how you approach the SP is another one third and practicing patient approach and responding to challenging questions will secure you the points on the exam and in the real thing as well.

5

CHAPTER ONE

HISTORY

6

SAMPLE of how you should divide your history and physical exam paper

Example 1

MR ADAM

55 yo

Vs WNL

Mental check list

1-

2-

3-

4-

HPI + ROS

L

I

Q

O

R

A

A

P

A

P

A

M

H

S

F

O

S

S

Positives in physical exam

Points to council the patient on at the end of the encounter

7

Example 2

MR ADAM Mental check list:

50 yo 1-

Vs WNL 2-

3-

HPI + ROS

L I Q O R A A P A

P A M H S F O S S

Positives in physical exam points to council patient on

History taking

8

Is divided into 3 main parts:

1- HPI (history of present illness) + ROS (review of systems) + History to think about.

2- PAM-HS-FOSS.

3- PSYCHIATRIC HISTORY.

HPI

1- Analysis of the CC which is divided into:

-PAIN LIQOR-F-AAPA stands for (location, intensity, quality, onset course duration, radiation, frequency, alleviating factors, aggravating factors, ppt event and associated symptoms)

-ANY OTHER CC OCD-F-AAPA stands for (onset, course, duration, frequency, aggravating, alleviating, ppt event and associated symptoms).

HISTORY TO ASK IN SPECIFIC CASES:

1- ANY FLUIDS (sputum, blood, discharge, vomiting) amount (teaspoon, tablespoon or cup full), color, odor, if not blood whether it contains blood or not, vomiting (projectile or not?), bleeding per rectum (bright red or mixed with stools?).

2- MUSCLOSKELETAL swelling, redness, morning stiffness, pain in other joints, bone fractures, numbness, tingling and weakness.

3- ENURESIS nights/week, episodes/night, amount/episode and particular time during the night + stresses, environmental changes, sleep apnea (snoring, night awakening), interventions and drugs tried.

4- CONFUSION OR FORGETFULLNESS problems with the DEATH-SHAFT stands for (dressing, eating, ambulating, toileting, hygiene, shopping, housekeeping, accounting, food preparation, transportation).

5- EAR SYMPTOMS hearing loss, vertigo(sensation of room spinning or feeling of imbalance), tinnitus, discharge, pain.

6- CHRONIC DISEASE FOLLOW UP(DIABETES & HTN) OCD + ROS + controlled or not, last measurement, medications ( current, previous eg.insulin in diabetes, compliance, doses, sideffects), side effects of disease (retinopathy, stroke, nephropathy, intermittent claudication, angina, MI)

7- INSOMNIA 4D-N-4S (Daily sleep habit, Duration of sleep, Difficulty falling asleep, Difficulty staying asleep, Night mares, Snoring, Sleepiness during the day, Smoking or alcohol or coffee before sleep, Seeing TV in bed)

8- SEIZURES ABCD, Aura (signs that the attack will happen),

Bowel/bladder control, Bite tongue, Consciousness lost, Confusion after regaining consciousness, Describe it.

9- AMENORRHEA .Hot flushes, vaginal dryness/itching (Menopause/premature ovarian failure)

.Nipple discharge, visual changes, headaches (Hyperprolactinemia)

9

8- SEIZURES ABCD, Aura (signs that the attack will happen),

Bowel/bladder control, Bite tongue, Consciousness lost, Confusion after regaining consciousness, Describe it.

9- AMENORRHEA .Hot flushes, vaginal dryness/itching (Menopause/premature ovarian failure)

.Nipple discharge, visual changes, headaches (Hyperprolactinemia)

19- HEARING LOSS Ear symptoms, exposure to loud noises, insertion of

foreign bodies, neurological problems (weakness, numbness, tingling), severity(mild, moderate, severe)

20- DIFFICULTY SWALLOWING OCD-F-AAPA, exact Location, Liquids or solids or both (if both which first?)

10

19- HEARING LOSS Ear symptoms, exposure to loud noises, insertion of

foreign bodies, neurological problems (weakness, numbness, tingling), severity(mild, moderate, severe)

20- DIFFICULTY SWALLOWING OCD-F-AAPA, exact Location, Liquids or solids or both (if both which first?)

34- BURNING URINATION IN YOUNG FEMALE OCD-F-AAPA, CD-PPP (for

vulvovaginitis, PID).

35- DRUG REFILL OR FOLLOW UP HTN DM HIV 1- disease: OCD

11

2-Schematic drawing for associated symptoms to ask specific to the system of the CC:

34- BURNING URINATION IN YOUNG FEMALE OCD-F-AAPA, CD-PPP (for

vulvovaginitis, PID).

35- DRUG REFILL OR FOLLOW UP HTN DM HIV 1- disease: OCD

12

ABDOMEN

RESPIRATORY AND CARDIAC

NEUROLOGICAL

13

OB/GYN (CD-PPP)

ROS

14

History to think about

These are important points in different cases that are commonly missed, you will not necessarily ask all of them in every case but you should think about them and ask what is relevant to the case.

1-Trauma.

2-Travel.

3-Testing for TB or Exposure to TB.

4-Testing for HIV (as in high sexual risk practice e.g. Multiple sexual partners or homosexual or sore throat cases).

5-Sick contacts (ie, sick contacts at day care center).

6-Screening tests (as in terminal cancer case).

7-Rash.

8-Vaccines ( as in over 50 patients and pediatric cases)

PAM-HS-FOSS

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P Past history similar problems.

Past history of medical problems.

A Allergies.

M Medications (prescription and over the counter).

H Hospitalizations and past surgical history.

S Sleep problems.

F Family history (similar problems, parents alive, medical problems)

O OB/GYN ( this is asked in case of a female and the CC is not related to OBGYN, so, only ask about LMP and whether cycles are regular or not)

S Social history (diet,appetite,weight / smoking,alcohol,illicit drugs / occupation,exercise,family stress).

S Sexual history (sexually active? Who is your partner? If not his wife ask do you use any method of contraception? If condoms, ask used regularly or not?)

Psychiatric history

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Is divided into: 1- HPI = TT-DSM-FAWR + ROS

2- PAM-HS-FOSS

Think what do you think your problem is related to?

Thyroid cold or heat intolerance, voice change, tremors, hair fall,

Palpitations.

D Duration of symptoms.

Daily routine

Delusions and hallucinations (do you see or hear things that others don’t?)

S Support (do you have someone to talk to when depressed?)

Suicide (considered ending your life? Plan? Guns or pills at home?)

Sense of guilt.

M Mood (what has been your mood lately?)

Memory (do you have problems remembering things?)

MMSE (discussed in details in neurological exam)

F Feeling lonely (have you been feeling lonely lately?)

A Anxiety (have you been feeling anxious lately?)

WR Realize (do you realize you have a problem?)

Willing (are you willing to get help?)

Mnemonic for the depression symptoms: SIG-ME-CAPS (all covered within the general scheme)

Sleep, Interests, Guilt, Mood, Energy, Concentration, Appetite, Psychomotor agitation or slowing, Suicidal ideation.

17

CHAPTER TWO

PHYSCIAL EXAMINATION

Physical exam

18

The examination room is equipped with all the instruments that you are suspected to use during the physical exam, and these are:

1. Ophthalmoscope. 4. Cotton tips, tooth picks.

2. Otoscope. 5. Tongue depressors

3. BP cuff and monitor. 6. Tuning fork, hummer.

The physical exam is divided into:

1. General exam.

2. Systems examination.

3. Miscellaneous examinations.

General examination

These examinations are not necessarily done routinely in every case, but you should think about them and do what is relevant to the case.

Head Tender sinuses.

Eye Conjunctive for pallor.

Fundoscopic exam.

Nose For nasal discharge.

Throat Pharyngeal injection and tonsillitis.

Ear Ear discharge.

Otoscope.

Neck LNS.

Thyroid + reflexes + hand tremors.

Carotid bruit auscultation.

Extremities Pulsations (radial and dorsalis pedis)

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LL edema.

Skin.

Systems examination

Chest examination: (patient sitting or lying down)

1. Inspection: Distress Depth,rhythm,rate Deformity.

2. Palpation: Trachea Tenderness TVF Thumb-expansion

Tachycardia(PMI).

3. Percussion.

4. Auscultation: if TVF +ve do bronchophony and whispering pectoriloquy (ask the patient to say 99 loud and while whispering while you are auscultating)

Cardiovascular examination: (sitting lying down sitting again)

A. Sitting: PULSE Carotid + bruit

Radial

Pedal + edema

B. Lying down:

1- Inspection, palpation: Pulsation of jugular vein at 30 degree.

Pulsations (aortic, pulmonary, sternal)

PMI (LIQ location, inch, quality)

2- Auscultation: 4 areas (aortic, pulmonary, mitral and tricuspid)

C. Sitting: Auscultate the 4 areas.

Abdominal examination: (lying down)

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1. Inspection: Swelling Scar Pulsations Peristalsis.

2. Auscultation: Bowl Bruit

3. Percussion: 4 quadrants.

Liver (MCL up down and down up)

Spleen (last intercostal space AAL deep breath percuss again dull=splenic enlargement)

Shifting dullness.

4. Palpation: Superficial (watch the SP face)

Deep palpation.

Liver

Spleen

5. Special exam: Tenderness Rebound (pain on releasing hand), done if tenderness on palpation.

CVA (pain on CVA percussion)

Suprapubic tenderness.

Signs Psoas sign (extension of Rt hip in left lateral position causes pain in appendicitis)

Obturator sign (flexion of Rt hip with internal rotation cause pain in appendicitis)

Rovsing’s sign (deep pressure in LLQ causes pain in RLQ in appendicitis)

Murphy’s sign (on deep palpation of the RUQ with inspiration pain occur and patient stop breathing)

N.B: Tell the SP that you will need to do inguinal/rectal exam if male and pelvic/rectal exam for female as these are forbidden during the exam.

Neurological examination:

21

1- Mental status : can be done at end of the history, beginning of physical or end of physical exam.

Orientation tell me your full name? where are we? What day it is?

Memory SHORT I will say 3 words and I want you to repeat them(pen, pencil, car) immediately and after 5 minutes so please remember them.

LONG who was the previous president of the states?

Abstraction could you please say the word “WORLD” backward.

Judgment please take my pen with you right hand put it in your left hand and give it back to me.

2- Cranial nerves :

Optic cover each eye and count fingers.

Eye movements (3,4,6)

Trigeminal palpate the masseter while the SP clinching his teeth.

Facial close your eyes please and don’t let me open them.

can you smile please.

Vestibulocochlear rub your fingers near the patient ears to see if he hears it.

Vagus and glossopharyngeal please open your mouth and say”AH”

Accessory please shrug your shoulders (against hand resistance)

Hypoglossal please stick out your tongue and move it form side to side.

3- Motor:

a. Muscle tone: “I would like to examine your muscle tone, please relax your muscles, ok?” Flex and extend the wrist and elbow, knee and ankle.

b. Muscle strength: “I would like to examine your muscle power, ok?” “pull in and push out maneuvers”

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4- Sensory: “I would like to check sensory perception in different areas of your body, ok?”

a. Light touch(cotton), Pain(tooth pick):

“This is dull and this is sharp, please close your eyes and tell me whether its dull or sharp when I touch you?”

b. Vibration, position:

Done if abnormalities in light touch and pain.

Tuning fork placed on/change in position of DIP of index finger and big toe.

c. Special tests for meningitis:

Neck stiffness flexion of patient’s neck causes pain.

5- Reflexes: “I would like to check your jerks, please relax your muscles?”

UL Triceps, Biceps(tape on your finger), Brachioradialis.

LL Knee, Ankle + Babinski

6- Cerebellar function: “I would like to check your balance and movement, ok?”

a. Gait: GET UP AND GO TEST “please get up and walk toward the

wall and back”

b. Romberg’s test: “please stand with your feet together and arms

extended, close your eyes I wont let you fall”

c. Finger to nose test: “please extend your arm then touch your nose, now

do it while your eyes are closed”

Grading of muscle power: Grading of reflexes:5/5 normal 0 absent4/5 less than normal 1 hyporeflexia3/5 not against resistance 2 normal2/5 not against gravity 3 hyperreflexia1/5 flicker 4 hyperreflexia + clonus0/5 absent

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MISCELANEOUS EXAMINTAION

A- EYE EXAMINATION:

1. Conjunctiva : “please look upwards” while you are pulling the lower

lids downwards.

2. Count fingers: “please put your Rt hand on your Rt eye and count my

fingers”.

2. Movement of extra ocular muscles : “please follow my finger to

examine your eye movement”. Lt thumb on the chin

to fix the head and the Rt index moves in the 3

cardinal positions on the Rt and vice versa.

3. Fields examination : (remove your glasses) done in 2 ways:

“please close your Rt/Lt eye and tell me how many

fingers do you see/when you see my finger”

Counting fingers ask the patient to close one eye and

you close the opposite one and then use both hands to make

counting fingers in both temporal and nasal fields, upper and

lower quadrants.

Moving finger as above but instead of counting fingers

move your index fingers from outward inwards in both fields

and both quadrants.

4. Fundus examination : (remove your glasses) “I will now dim the light

to examine your retina please look straight ahead”

use the Rt hand and Rt eye to examine the patient’s Rt eye and

vise versa.

B- MUSCULOSKELETAL EXAMINATION:

24

1- Inspect and compare (don’t forget the back of the areal you examine)

Appearance Atrophy Deformity Swelling Redness

2- Palpate and compare

Temperature Motion range Pulsations

Tenderness Motor, sensory, reflexes

B- EAR EXAMINATION:

Special situations:1- UPPER EXTREMITY PAIN

Neck range of motion. Adson’s test (palpate radial pulse while the patient extend his neck to

the opposite side for thoracic outlet syndrome) Tinel test (Tap median N. on wrist for carpal tunnel syndrome) Phalen test (Flex wrist for carpal tunnel syndrome)

2- BACK PAIN Spinal and Para spinal tenderness (lumber strain) Straight leg raising test (lumbar disk prolapse, L4-decreased knee

jerk, L5-decreased big toe dorsifexion, S1-decreased ankle jerk)

Eye examination for uveitis (ankylosing spondylitis)3- DVT homan’s sign (dorsifexion of foot produces cuff pain), in cases

of chest pain, dysnea and LL pain.4- EYE EXAMINATION in cases where uveitis may occur ( back pain,

rash, wrist pain, knee pain)5- KNEE TRAUMA examine for: Drawer, McMurray’s, Effusion.6- IN ANY JOINT PAIN examine the joints of the hands.

25

1. Inspect and palpate + mastoid “please tell me if you feel pain”

2. Hearing : Whisper “please cover your Lt/Rt ear” whisper in the other ear with

pen/light and ask the SP to repeat. Rene test (normally AC>BC, positive) Weber test (normally no lateralization, negative)

3. Otoscope exam: rest your hand on the mastoid process.

C- NOSE EXAMINATION:

1. Inspection: “Please tilt your head backward” use the otoscope as a light pen to examine the nose.

2. Sinuses examination: “I will press on your face, please tell me if you feel pain.”

Frontal Ethmoid Maxillary

D- THROAT EXAMINATION:

“Please open your mouth and say AH” use a tongue depressor. “Please stick out your tongue” inspect upper and under surface.

N.B: ENT are always examined together.

E- NECK EXAMINATION:

1. Inspection: Swelling Scars Symmetry

2. Palpation: Tenderness Thyroid anterior approach: press on one lobe with

your fingers while you examine the other from inside out toward the sternomastoid with the thumb.

Posterior approach: examine both lobes together in a rolling movement while the SP swallows.

4. Lymph nodes: Posterior occipital post auricular anterior auricular submandibular submental superficial and deep cervical supraclavicular

N.B: forbidden examination (not done but tell the SP you will need to do them if indicated) female breast, pelvic, rectal, genital, corneal reflex and inguinal hernia examination.

F- EXAMINATION IN SPECIAL SITUATIONS:

26

If PE in DD (SOB and/or Cough) calf tenderness.

Difficulty swallowing give the patient water and ask him to

swallow.

Motor vehicle accident (MVA) HEENT, chest, heart, abdomen,

neurological (mental status/cr N./motor/sensory), skin for lacerations.

Hearing loss examine: ENT, Fundoscopic exam (papilledema),

neurologic (cr n., motor, sensory, reflexes, Cerebellar)

Insomnia: Throat, Neck for thyroid+reflexes, listen to the heart, palpate

abdomen.

HTN drug refill must record BP in both arms.

Any case with malignancy in DD examine for enlarged LNS.

Constipation Motor, Sensory, Reflexes in the LL.

DM drug refill FOOT EXAMINATION.

If the case is not a neurological case and you have neurological diseases in

DD examine Motor, Sensory and Reflexes, if your timing is tight at

least examine for Reflexes.

27

CHAPTER THREE

PATIENT NOTES

28

PATIENT NOTES

sample of the exam paper

Patient notes are written from the bottom to the top starting with the differential diagnosis diagnostic work up physical exam history.

Maximum of 5 DD and 5 diagnostic work up.

History

Physical examination

Differential diagnosis Diagnostic workup:1. 1.2. 2.3. 3.4. 4.5. 5.

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WRITING THE PATIENT NOTES

HISTORY:

General format of the HPI: … Yo F/M c/o …., LIQOR-F-AAPA or OCD-F-AAPA, patient recalls/associated with ………, patient denies/not associated with…….

Points to be covered in the history are: HPI, ROS, PMH, PSH, ALLERGY, MEDICATION, FH,

OBGYN,SH, SxH.

History to be added in pediatric cases: BIRTH H, DEVELOPMENTAL H, IMMUNIZATION H,

FEEDING H.

History documentation in PSYCHIATRIC CASES: A-DSM-PTCI

A Appearance. Affect mood congruent.

D Delusions and hallucinations Duration.

S Suicide. Speech scant or excessive, goal oriented or not.

M Mood MMSE

P Past traumatic event.

T Thyroid.

C Concentration.

I Insight (does the patient realize he has a problem).

PHYSICAL EXAMINATION:

30

Normal in physical examination: VS (vital signs): WNL HEENT (head,eye,ear,nose,throat) :

Normocephalic, atraumatic, no bruises (in trauma or domestic violence) Nose, mouth and pharynx WNL (in case of URI) PERRLA(pupils equal round reactive to light and accommodation),

EOMI(extra ocular movement intact), no Fundoscopic abnormalities, no nystagmus.

No cerumen, TMs normal, + rene, - weber, no tenderness (for ear exam). Rash: multiple circumscribed erythematous lesions, no pigmentation, scales

or jaundice noticed.

NECK: Supple, no lymphadenopathy (head and neck infections or metastatic cancer). No JVD, no carotid bruit (in cardiovascular examination)

HEART: Apical impulse not displaced, RRR (rhythm,rate,regular), normal S1 and S2,

no murmurs, rubs or gallops.

CHEST: No tenderness, clear breath sounds bilaterally, no rales, wheezes or ronchi,

trachea central, tactile fremitus normal.

ABDOMEN: Soft, non distended, non tender, +bowel sounds, no organomegaly.

( S/ND/NT/+BS/no organomegaly)

NEURO: Mental status: alert, orientedx3, spells backward, recall 3 objects. Cranial nerves: 2 to 12 intact Motor: 5/5 upper and lower extremities. Sensory: intact to touch and pinprick. DTRs: 2+ symmetric in upper and lower extremities, - babinski. Cerebellar: - Romberg, gait normal.

EXTREMITIES: No clubbing, cyanosis or edema. Pulses 2+ and symmetric. No tremors.

OB/GYN:

31

G…P..., LMP…, regular/irregular, painful or not, bleeding or not (postcoital and/or intermenstrual), discharge or not, no history of abnormal pap smear.

MUSCLOSKELETAL: No warmth or erythema, no tenderness, normal range of motion,

motor/sensory/reflexes, pulsations

DIAGNOSTIC WORKUP:

1- Forbidden examinations.2- CBC with differential.3- Blood tests.4- Radiological tests.5- Special tests.6- complications of the disease (ie obesity glucose, cholesterol, TGs),

diarrhea electrolytes)7- Age related screening test.

Electrolytes are a common investigation to order. Similar tests could be written in the same line.

DIAGNOSTIC WORKUP IN SPECIAL CASES:

Diabetic patient blood glucose, Hb A1C and urinalysis for microalbuminuria

Drug abuser serum and urine toxicology screens. Diarrhea rotavirus enzyme immunoassay, Stool leukocytes,

culture, ova, parasites and PH, AXR, electrolytes, cl. Difficile toxin. Hearing loss audiometry, tympanometry, brain stem auditory evoked

potential, VDRL or RPR(syphilis cause menier’s), CT head. Back pain XR lumber sine, MRI lumber spine, PSA, Calcium,

BUN/CR, serum and urine protein electrophoresis. (Multiple Myeloma). Any neurological or psychological case electrolytes, serum and urine

toxicology screen. Any cardiological case, DM and HTN Lipid profile. Enuresis genital exam, renal US, UA and culture, first morning urine

specific gravity. Shortness of breath CXR, ABG, pulse oximetry, sputum gram stain,

AFB and cultures. Any bleeding Postural BP and HR measurement, PTT/PT/INR, BMP

(Na, K, co2, CL, HCO3,PH). Impotence TSH, PRL, Testosterone, Nocturnal penile tumescence test. Any DD with peptic ulcer H.plyori serology, upper GI endoscopy. First prenatal visit TORCH screen, hepatitis B/C screen, HIV screen,

Blood typing and grouping, UA and culture, abdomen US.

DIFFERENTIAL DIAGNOSIS:

32

Maximum of 5. Written in descending order of likelihood. Thyroid problems and drug induced disorder are common in DD. Mostly will be diseases from the mental check.

Any DD could be divided into systems and then categories:1- Systems: neurological, chest, heart, abdomen, musculoskeletal and HEEENT.2- Categories: functional, traumatic/mechanical, inflammatory/allergic,

metabolic/endocrine, neoplastic, vascular/blood, psychological, drug induced.

DD in cases like (bilateral leg pain, unilateral leg pain, bilateral arm/UL pain, unilateral UL pin…..etc) will be divide into:

1- Structures: skin, bone, muscle, nerves, arteries and veins.2- Categories: as before.

33

CHAPTER FOUR

DIFFERENTIAL DIAGNOSIS OF IMPORTANT PRESENTATIONS

DD OF IMPORTANT PRSENTATIONS:

34

(The aim of this list is to help you make a DD in your mind before the encounter; it is not conclusive of all the DD of each symptom)

CHEST PAIN:1. Heart: MI, angina, pericarditis, arrhythmias.2. Lung: PE, pleuritis, pneumonia.3. Chest: costochondritis.4. Esophagus: GERD, perforation, obstruction.5. Aorta: dissection6. Psychiatric: panic attack.

ACUTE COUGH (<3weeks):1. Common cold2. Acute sinusitis3. Acute bronchitis4. Bronchial Asthma5. PE6. GERD7. Pneumonia8. Drugs: ACEI.

ACUTE SHORTNESS OF BREATH:1. PE2. CHF3. COPD exacerbation4. Bronchial Asthma5. Anxiety, Panic attack.6. Pneumothorax.

COUGH AND CHEST PAIN:1. Pneumonia2. Pleuritic pain3. TB4. Lung cancer5. PE6. GERD

CHRONIC COUGH:1. Posterior nasal drip 2. Chronic bronchitis3. Bronchiectasis4. TB5. Lung cancer6. GERD

SORE THROAT:1. Bacterial pharyngitis (streptococcus pneumonia, gonococcal, mycoplasma)

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2. Viral pharyngitis3. Posterior nasal drip4. GERD5. IMN6. 1ry HIV

HEMOPTYSIS:1. Pneumonia2. PE3. Bronchiectasis4. TB5. Malignancy6. Bronchitis7. CT disease8. Pseudohemoptysis.

SICKLE CELL ANEMIA WITH CHEST PAIN:1. Vaso-occlusive crisis chest syndrome2. Pneumonia3. Osteomyelitis (salmonella)4. PE

PALPITAIONS:1. Cardiac: Arrhythmias, valvular disease, PE.2. Metabolic: hypo or hyperthyroidism, Pheochromocytoma, Hypoglycemia.3. Psychiatry: Anxiety, Panic attacks.

ACUTE DIARRHEA (<4weeks):1. Viral GE2. Bacterial GE3. IBD4. IBS5. Malabsorption6. Cl difficile colitis7. HIV

CHRONIC DIARRHEA:1. Osmotic: laxatives, malabsorption2. Inflammatory: IBD, IBS, giardiasis3. Secretory: infections, VIPoma, cholera4. Motility: hyperthyroidism

DIARRHEA (PEDIATRICS):1. Rota virus2. Bacterial diarrhea3. Malabsorption4. UTI5. Sepsis6. Intussusception

CONSTIPATION:

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1. Functional2. Obstructive: cancer, intestinal obstruction3. Metabolic: hypercalcemia, hypothyroidism, DM4. Neurologic: stroke, MS, PN, spinal cord lesions5. Medications: opiates, iron, anticholinergics

VOMITING OF BLOOD:1. Esophagus: varices, Mallory Weiss syndrome, cancer.2. Gastric: PUD, gastritis, cancer.3. Pseudohemoptysis

NAUSEA AND VOMITING:1. Gastroenteritis2. Intestinal obstruction3. Inflammation: PUD, Appendicitis, Pancreatitis, Pyelonephritis4. Neuromuscular: GERD, DM5. Intracranial: Malignancy, infection6. Medications: Digoxin7. Pregnancy8. Anorexia Nervosa.

RECTAL BLEEDING:YOUNG

1. Anal: fistula, fissure, hemorrhoids.2. Rectal: gonococcal proctitis.3. Colon: IBD, infective colitis, cancer, vascular ecstasies.

OLD1. Diverticulosis/Diverticulitis2. Cancer3. Angiodysplasia4. Ischemic colitis

DIFFICULTY SWALLOWING:OROPHARYNGEAL

1. Mechanical: zenckers diverticulum, laryngeal carcinoma2. Neurological: CVA, MS3. Muscular: myasthenia gravis, muscular dystrophy.

ESOPHAGEAL1. Cancer2. Achalasia3. Scleroderma4. GERD

DIFFICUTY WITH URINATION:

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1. BPH2. Prostatic carcinoma3. Urolithiasis4. UTI5. Urethral stricture6. Bladder cancer7. Neurological: Spinal cord trauma, DM

BURNING WITH URINATION:1. Pyelonephritis2. Cystitis3. Uretheritis4. Vulvovaginits5. PID

INCREASED URINATION:1. DM2. DI: neurogenic, nephrogenic.3. Psychogenic polydypsia4. UTI5. Medications: diuretics6. Hypercalcemia

DARK URING (BLOODY URINE):1. UTI2. GN3. Urolithiasis4. Renal, ureteral or bladder cancer5. Conjugated hyperbilirubinemia6. Medications

BILATERAL LEG PAIN:1. Thromboangitis obliterans2. Atherosclerotic vascular disease3. Lumber spinal stenosis4. Statins5. Diabetic polyneuropathy6. Radiculopathy.7. Varicose veins

UNILATERAL LEG PAIN:1. Cellulitis2. DVT3. Ruptured backer’s cyst4. Osteomyelitis5. Traumatic.6. Varicose veins

BACK PAIN:1. Lumber disc prolapse

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2. Lumber muscle strain3. Lumbar spinal stenosis4. Osteoporosis5. Degenerative arthritis 6. Multiple Myeloma7. Spinal metastasis8. TB of the spine “pott’s”9. Ankylosing spondylitis

KNEE PAIN AND SWELLING:1. Trauma2. Osteoarthritis3. Septic arthritis4. Lyme disease5. Mono articular RA6. Gout7. Pseudo gout8. Reactive arthritis9. Psoriatic arthritis

SHOULDER PAIN:1. Dislocation2. Fracture3. Rotator cuff tear4. Subacromial bursitis5. Ligamental strain

UPPER EXTREMITY PAIN:1. Cervical disc prolapse2. Cervical spondylitis3. Thoracic outlet syndrome4. Tenosynovitis5. Carpal tunnel syndrome6. Trauma

HEAL AND FOOT PAIN:1. Planter fasciitis2. Calcaneal periostitis3. Calcaneal spur4. Painful heel pad syndrome5. Stress fracture

RASH:1. Infectious: impetigo, rubella, measles among others2. Insect bite3. Allergic4. Autoimmune: RA, SLE5. Photo dermatitis6. Occupational exposure

MULTIPLE BRUISES:1. Accident

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2. Domestic violence3. Bleeding disorder4. Autoimmune collagen vascular disease

IMPOTENCE:1. Vascular: atherosclerosis2. Neurological: DM neuropathy, spinal cord lesion3. Endocrinal: pituitary lesion, medications4. Psychiatric: anxiety, depression

INSOMNIA:1. Medical: COPD, CHF, PUD, hyperthyroidism2. Psychiatric: anxiety, depression, PTSD3. Sleep apnea4. Irritable leg syndrome5. Circadian rhythm disorder6. Menopause7. Medications8. Malignancy

FREQUENT FALL:1. Parkinsonism2. Cerebellar lesions3. Seizures4. Vertigo5. Orthostatic hypotension: e.g. DM6. Vascular: TIA

SEIZURES:1. Trauma2. Infection3. Medication induced or withdrawal4. Metabolic5. Vascular: e.g. Stroke6. Tumor7. Hypoglycemia8. Syncope9. Intoxication

ARM AND LEG WEAKNESS:1. Stroke2. TIA3. SDH4. SAH5. Guillan Barre syndrome6. Complex migraine7. Conversion disorder

HEADACHE:1. Primary:

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Migraine, cluster headache, tension headache2. Secondary:

Extra cranialGlaucoma, errors of refraction, OM, temporal arteritis, sinusitis, dental disease, cervical spine lesion

Intra cranialInfection (meningitis, encephalitis), SAH, tumor, pseudo tumor cerebri

CONFUSION:1. TIA and stroke2. Dementia: Alzheimer’s, multiinfarct dementia3. Depression4. Metabolic: hypothyroidism, hypoglycemia5. Medications6. Infections: meningitis, encephalitis

DIZZINESS:1. Neurological: infections, vascular, tumor, traumatic, migraine2. Cardiological: AS, arrhythmia, HOCM, acute coronary syndrome3. Ear diseases: OM, menier’s, benign positional vertigo, labyrinthitis4. Metabolic: hypoglycemia, hypothyroidism, anemia5. Panic attacks6. Orthostatic hypotension

SPELLS OF LOC:1. Neurological: TIA, stroke, seizures, migraine2. Cardiac: arrhythmias, CAD, AS, HOCM3. Psychiatric: conversion disorder4. Vasovagal attack5. Orthostatic hypotension

BLURRING OF VISION:1. Diabetic neuropathy2. HTN neuropathy3. Cataract4. Glaucoma5. Temporal arteritis6. Infection: uveitis, optic neuritis, orbital Cellulitis7. Brain lesions: optic glyoma, occipital lobe lesions

HEARING LOSS:Conductive

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FB, cerumen impaction, TM perforation, post OM effusion, otosclerosis, cholesteatoma

SensorineuralPresbycusis, noise induced, ototoxicity, menier’s disease, acoustic neuroma

NOSE BLEED:1. Trauma2. Bleeding tendency3. Nasopharyngeal angiofibroma4. FB5. Wegner’s granulomatosis6. Medication induced7. Thrombocytopenia

AMENORRHEA:1. Pregnancy2. Hypothyroidism3. Prolactinoma4. PCO5. Stress induced: excessive exercise6. Anorexia nervosa

HOT FLASHES:1. Menopause2. Premature ovarian failure3. Hyperthyroidism4. Carcinoid syndrome5. Chronic fatigue syndrome6. Occult malignancy7. Factitious disorder

VAGINAL BLEEDING:1. Regular menses2. Abortion3. Ectopic pregnancy4. Hydatiform mole5. Malignancy: endometrial, cervical and estrogen producing endometrial

cancer6. Traumatic7. Bleeding tendency

CHILD WITH FEVER:

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1. Respiratory tract infection2. OM3. Exanthematous disease4. Meningitis5. Encephalitis6. UTI7. GE

CHILD WITH VOMITING:1. GE2. Intestinal obstruction3. GERD4. Pyloric obstruction

NIGHT SWEATS:1. Infections: TB, HIV2. Malignancy: Lymphoma3. Endocrine: Hyperthyroidism, Pheochromocytoma4. Medications

ENURESIS:1. Primary nocturnal enuresis2. Secondary enuresis3. UTI4. Constipation5. Sleep apnea

FATIGUE:1. Occult malignancy2. DM3. TB4. HIV5. Depression6. Hyperthyroidism7. Malabsorption8. Addison’s disease9. Anemia

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CHAPTER FIVE

CLOSURE AND COUNCELLING

ENRANCE, CLOSURE AND COUNSELLING

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ENTRANCE?

Knock and enter You: “Hallo Mr/Mrs …… I am dr ….. I am ……, are the room settings

comfortable?” SP: “yes” You: “ok Mr/Mrs …… how may I help you?” SP: “I have back pain” You: “oh I am so sorry to hear that, ok Mr/Mrs ….. First we will talk about

your problem then I will need to do a brief physical examination and I will be as fast and as gentle as possible, ok?”

SP: “ok doctor, thank you” You: “could you tell me more about your problem please?”

GERNERAL COUNSELLING:

You: “Thank you Mr/Mrs …… for your cooperation, let me give you my impression, you told me you have …..(give a very short to the point briefing of the history)… is that right”

SP: “yes” You: “and from the physical exam, I am thinking your problem may be related

to ….(give the most likely disease)… which is …..(give brief explanation)…. But we can not be sure yet we will have to run some tests first, then I will sit with you again to explain the results, tell you the final diagnosis and agree on a management plan, is that ok?”

SP: “yes doctor” You: “do you have any questions or concerns?” SP: will give you the challenging question if he hasn’t already or will say “no

doctor thank you” Shake hands saying “it was nice meeting you, I will do my level best to help

you” and leave the room.

COUNSELLING IN SPECIAL SITUATIONS:

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COUNSELING IN DOMESTIC VIOLENCE: (spousal, child or geriatric abuse)

Mr/Mrs ……. I am concerned about your safety. I am always available for help and support whenever you need it. Every thing we discuss is confidential but I have to involve child protective

services if your children are being abused. We have a lot of resources to help you like support groups, I will give you

their contact information, do you have any questions or concerns?

COUNSELLING IN ENURESIS:

Don’t worry Mrs …… this is a common problem in children. However it can be embarrassing to the child and stressful to the family. Most cases can be treated with life modifications without the need for drugs,

here what I want you to do:1. monitor fluid/day2. limit fluids before sleep3. bathroom before sleep4. wake 2-3 hrs after sleep to go to bathroom5. make him/her change his/her pajamas6. give reward for the dry nights7. bedwetting alarm that rings at the beginning of bedwetting

COUNSELLING IN OBESITY:

Restrict fatty food Regular exercise Radical change in diet habits is not recommended Read books about obesity and loosing weight Consult a dietitian

SMOKING AND ALCOHOL COUNSELLING:

You: “Mr/Mrs …… I am concerned about your smoking/alcohol drinking, smoking causes a lot of health hazards like heart attacks, strokes, lung cancers, urinary cancers and stomach ulcers among users/alcohol cause a lot of health hazard like liver cirrhosis, pancreatitis, gall bladder stones and stomach ulcers among others, Are you willing to quit smoking/alcohol drinking?”

SP: “NO” You: “ok Mr/Mrs ….., I understand you are not ready now to quit

smoking/alcohol drinking, when you decide to quit I will be here to offer you all the support you need, also, we have a lot of resources to help you quit through our social workers”

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SP: “YES” You: “I am glad you made that decision, I will be here to offer you all the

support that you need, also, we have a lot of resources to help you quitting and I will make you an appointment with one of our social workers, ok?”

SP: “ok, thank you doctor”

COUNSELLING IN ANY PSYCHIATRIC CASE SHOULD INCLUDE:

I am willing to talk to your family to be more supportive if you want. I will be here to offer you all the support that you need during treatment.

COUNSELLING IN PEDIATRIC CASES SHOULD INCLUDE:

Mrs ….. I am concerned about your child problem and I want you to bring him/her to the hospital as soon as possible to examine him/her and to order some tests, if you are not able to bring him/her to the hospital I can arrange someone to pick him/her up from home.

Meanwhile I would like you to …. (Give him Tylenol and cold compresses if he has fever for example)…

COUNSELLING IN TERMINAL CANCER PATIENTS:

Mr/Ms….. I understand what you are going through. I will be giving you something to relieve your pain and I am always here to be of any support to you at any time.

I want you to be aware of things that will be necessary later on in your life:1. Living at home or nursing home?2. Hospice: completely supervised medical, psychological and physical

support that is provided at home at terminal stages of disease to let patients live as comfortable, pain free and as full as life as possible.

3. Advance directive: living will that enable the patient to say how he or she want to be treated at terminal stages of his/her illness when no more able to make decisions.

COUNSELLING IN DIAGNOSED OR HIGH RISK HIV CASES:

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Safe sexual practice (use of condoms regularly, inform partner, avoid high risk sexual behavior like multiple partners)

Treatment, side effects and management Vaccinations (only killed vaccines, e.g. Influenza, Hepatitis A) Support system

COUNSELLING IN DM:

Diet, exercise and medications

COUNSELLING IN FIRST PRENATAL VISIT:

Work up: HIV consent, TORCH, blood typing and grouping, hepatitis screening.

Supplements: iron, vitamins, nutritious diet, calcium Safe sexual practices Regular antenatal visits

COUNSELLING HEEL/FOOT PAIN:

RICE (rest for 3 days, immobilization, cold compresses 30min/d, elevation)

Ibuprofen Avoid exercise or weight bearing Soft heel pads Padded foot splint during sleep

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