Diarrhea(ped) DDx -gastroenteritis -food poisoning -UTI -URI -cow milk protein allergy DOPCSFAAA ABCO -When was he/she last well? -F=how many bowel movements does he/she have per day? -Does he/she usually have normal bowel movements? -A=Are his/her bowel movements related to oral intake or meal? -Did you seek for any treatment? URI URI -Has he/she had any respiratory tract infection recently? Fever -Does he/she have a fever? CMPA Rashes -Does he/she have any rashes? Breast-feeding-Does you breast-feed your child AGE/food poisoning N/V -Does he feel nauseated? -Did he/she throw up? Travel Hx -Has he/she traveled recently? Day care -Did he/she go to day care center? Ill contacts-Has he/she had ill contacts in day care center? Eating -Did he/she eat anything unusual? Severity Wet diapers -How many times he/she wet diapers? Vigorously cry-Does he/she cry vigorously? SOB -Does he/she breathe faster than usual? Shaking -Did he/she shake?

Hearing loss DDx 1.conductive HL -cerumen impaction -transient auditory tube dysfunction(URI, allergy) -Acute/chronic otitis meida -Otosclerosis -trauma -Glomus tympanicum (middle ear tumor) 2.sensorineural HL -Presbyacusis -excessive noise exposure -Menierre’s disease -Labyrinthitis -Head trauma -ototoxicity(from aminoglycoside, furosemide) 3.Neural -acoustic neuroma -CVA?? DOPCSFAAA -How did you know that? -tell me more about it. D-When have you first noticed? -Which side has the problem? -Did you seek for any treatment? Local คัน -Does your ear itch? ปวด -Does your ear ache? หนอง-Is there any discharge from your ear? HL and tinnitus- Is there any ringing in your ears? Vertigo problems 1.dizziness -Do you have any dizzy spells? -Do you feel the room spinning around you? 2.imbalane -Any trouble with your balance? 3.Vegetative -Do you feel nauseated? 4.nystagmus -Have you noticed any change in your vision? Neural -Do you have headaches? -Do you have weakness/ numbness? อื#นๆ -Have you ever had trauma to your ears? -Have you ever been exposed to loud noises?? -Have you ever inserted foreign bodies into your ears?

P.E. HEENT-จมูก ปาก คอ otoscope fundoscopy hearing Neuro. – CN, motor, sens., reflex, cerebrellum Bed wetting DDx -monosymptomatic primary nocturnal enuresis -secondary enuresis -urinary tract infection -constipation -sleep apnea -functional bladder disorder Lab -Genital exam -UA, urine culture -first morning urine specific gravity -U/S renal DOPCSFAAA F-How often does he wet his bed? -Is the problem in the night or all day? Does he have this problem both at night and during the daytime? -Have you ever tried to do anything to help him? -Does he drink or eat anything before he go to sleep? -Can you estimate the amount of his urine? -Does he have any pain during urination? -Does he feel the rush to go to the toilet when he wants to urinate? Or Does he feel as though he has very little time to make it to the bathroom once he feel the urge to urinate? -What is the color of his urine? -Is there any blood in it? -Does he have a fever? -Does he have abdominal pain? -Is he constipated? -Does he snore? -Does he have nighttime awakening? -Is there any environmental changes related to his bed wetting? -Does he have any stress? Accident+trouble breathing+excruciating pain -Tell me what happened?

-What were you doing? -Did you hit your head? -Where are you hurt? -Did you lose your consciousness? Or Were you unconscious? -Have you noticed any change in your vision? -Do you feel confused? -Do you lose your memory? -Is there any change in your personality? -Do you have any weakness/ numbness? -When was your last meal? -PAIN ->LODCRAFT อื#นๆ -cough, sputum, fever, palpitation, abdominal pain, N/V P.E. ทุกอย ่า ง Neuro. -mental status -CN -Gross motos Skin Blood in stool DDx -colorectal cancer

-anal fissure -Hemorrhoids -Diverticulosis -Angiodysplasia -Inflammatory bowel disease -Ulcerative colitis -Crohn’s disease -proctitis DOPCSFLIQRAAA ABCO D-When did it start? -Is it fresh blood or a dark color like tar? -Is the blood mixed in with your stool or does it appear on toilet paper when you wipe yourself? F-How often do you get this problem? -Do you vomit up blood too? Anal fissure pain-Do you have any pain in your back passage when you have a bowel movement? constipation-Are you constipated? diarrhea-Do you have diarrhea? F-How many bowel movements do you have per day? -Do you feel the rush to go to the toilet when you want to move your bowel? Or Do you feel as though you have very little time to make it to the bathroom once you have the urge to have a bowel movement? -Do you feel as though you strain to go to the bathroom and then very little feces or none at all come out? -Do you have cramps in your stomach? -Do you feel nauseated? เพิ $มเติม IBD -Is there any change in your bowel habit? Hemorrhoids -Have you felt any lumps at your back passage? -Is it painful? -Does it come and go? Can you push it back? -Do you feel faint? AGE -Have you had sick contacts with people with diarrhea? -Have you traveled recently? P.E. ทั#วไป

Jaundice

Prehepatic=hemolysis Hepatic Posthepatic (indirect) (direct) Obstructive Stones/cholang Tumor PBC/PSC Hepatitis tumor/mass toxic. Congen. Degen.=cirrhosis Biliary tr. Extra. -sphincter of Oddi -Ampulla of vater -CHCA -duodenal mucosa DOPCSF LIQR AAA D-When did you first notice? R/O Obstructive jaundice สีอึ ฉี&-Is there any change in the color of your stool/urine? คัน- Do you have any itchiness? Abd. Pain-Have you had abdominal pain?+DOPCSFLIQRAAA N/V – Do you feel nauseated? Diarrhea/constipation- Do you have diarrhea? Are you constipated? Fever(cholangitis) – Do you have a fever? Do you have chills?nightsweats? Bloated- Do you feel bloated after a heavy fatty meal? Hepatitis ปวดข้อ-Do you have any painful joints? Fatigue-Do you feel fatigued? Risk factors -Have you ever had a colonoscopy done before? -Have you ever received blood transfusion? -Have you traveled recently? -Have you had a vaccination before traveling? P.E. HEENT-ดูตา ดู ใต้ลิ)น , asterixis, spider nevi , palmar erythema, telangiectasis Pregnancy -How did you know you are pregnant? -Do you feel the baby moving? -LMP When was the first day of your last menstrual period?

-Menarche At what age did you have your first menstrual period? -I How often do you get your menstrual period? -D How long does it last? -amount How many pads or tampons do you use per day? -dysmenorrhea Do you have cramps? OB.Hx -Have you ever been pregnant? -Was it a vaginal delivery or a C-section? -Was your pregnancy full term? -How many times? How many children do you have? -How old is your first child? -How heavy was he at birth? -Did you have any complications during your pregnancy or during your delivery? -Did you smoke, drink, or use drugs during your pregnancy? -Did your child have any medical problems after birth? -Have you ever had a miscarriage or an abortion? -In what trimester? -Have you had a Pap smear before? GYN.Hx -How many sexual partners do you have? -Do you use any contraception? -Have you ever had a sexually transmitted disease? -Have you ever been tested for HIV? Hepatitis? Syphyllis? Pbl. Of pregnancy -Are your ankles swollen? -Do you have back pain? -Do you feel nauseated? -Do you have a fever? -Do you have abdominal pain? -Have you had any vaginal discharge or bleeding? -Have you had a rubella vaccination in the past? -Is there a history of birth problems in your family? -ask about previous blood transfusion. Examination Examined my eyes ( for pallor ) Examined Oral cavity ( For general hygiene ) Examined Legs ( for edema and varicose veins ) Auscultated Heart and Lungs Examined and Auscultated abdomen ( If less than 28 weeks just do Fundal grip; If more than 28 weeks do all the Leopold’s maneuver’s)

Pediatric Introduction and greeting:

-“Good MORning/ Good afterNOON, Mrs.Smith. Nice to meet you (SHAKE HAND with firm grip) My name is Dr.Thanaviratananich. I am a physician on duty here today. Today, I need to ask you some QUEStions about your child after that we will discuss together and if you have any questions please feel free to ask.. Is that OK with you?” -How can I help you today? -May I take a few notes while we talk? Fever(ped) DDx -sepsis -meningitis -pneumonia -UTI -URI -otitis media -occult bacteremia -gastroenteritis DOPCSFAAA ABCO -What brought your child here today? -How high is his/her temperature? -When did it start? Or when was he/she last well? URI/pneumonia -Does he have a runny nose? Does he have a stuffy nose/ a blocked nose? -Does he have a cough? Is it a dry cough or does he bring up any phlegm? -Does he breathe faster than usual? -Does he have difficulty swallowing?(dyspnea) Otitis media -Is there any discharge from his ears? Viral exanthem -Does he have a rash? AGE -Have you noticed any change in his/her bowel movement? UTI -Any change his-her urination? Meningitis -Does he shake? Sepsis -How has the baby looked? อื#นๆ -Has he ever contacted with ill people? -Did he go to daycare center? -Has he ever contacted with ill person in daycare center? -Have you taken him/her to see another doctor before you come here? -Have you tried giving her any medication or treatment? อย่าลื มถาม ill conract or daycare center Past Medical History

PAM HUGS FOSS “Okay, Mrs. Smith, now I need to ask you some questions about the child’s health in general.” Has he/she ever had the same problem before? Does he/she have any allergies? Does he/she have other medical illness? Is he/she taking any medication? Has he/she ever hospitalized before? Have you noticed any change in his/her bowel movement? How about his-her urination? Has he/she ever had surgeries before? Next, I would like to ask you some questions about your family s’ health. Does anyone in your FAmily have SImilar PROBlem? Are there any SErious MEdical conDItion in your family? Next, let s’ talk about birth history Were there any problems with the pregnancy? Was your pregnancy full term? Did you have any complications during your pregnancy/ during your delivery/ after delivery? Did you smoke, drink or use drug during your pregnancy? Was it a vaginal delivery or a C-section? Did your child have any medical problems after birth? Are your child’s immunizations up to date? When was the date of your child’s last routine checkup? How is your child’s appetite? Please tell me about his/her eating habits. And how about his/her sleeping habits. F/U DM Dx เมื$อไร -How long have you had diabetes? Tx อย่างไร -How have you been treated?

Compliance -Do you take the medication regularly? Drug S.E. -Has there been any adverse effects from your medications? Last doctor visit -When was the last time you visited your doctor? Or When was your last routine checkup? Eyes check -When was the last time you had your eyes checked? Monitor -How do you monitor your blood sugar level? -What was the result of the last time? How is your blood sugar level? -How about your HbA1C level? -How do you feel today? Complications สมอง -Do you have headaches? -Do you have weakness/ numbness? -Do you feel dizzy? ใจ -Do you have chest pain? -Do you have heart racing? ไต -Have you noticed any change in your urination ANS -Have you noticed any change in your bowel movements? -Do you feel nauseated? Do you vomit? Any abdominal pain? ตา -Have you noticed any change in your vision? ตีน -Do you have foot ulcers? Sex -Do you have problems with sexual functions? -Do you have any problems with erection? -How is your sexual desire? อื#นๆ -Do you feel depressed? -Do you have any problems with your family or your job? -Please tell me about your diet. PMH ถามเป็นโรคๆ -Have you ever had high blood pressure/ high lipid level/ a stroke/ heart problems? Cough อย่าลืม offer นํ#า/a tissue DOPCSFAAA +ABCO+LIQR(in case of chest pain) -Is it a dry cough or do you bring up any phlegm with your cough?+ABCO(How did it smell?) F-Do you have a cough at certain time of the day? Associated symptoms Before

-a fever -sore throat -a runny nose -Were there any symptoms before you get a cough? Like a runny nose, a fever, a sore throat? Now -a fever, chills, night sweats -Chest: SOB, CP, wheezing -TB:night sweats, lumps on your neck -Do you have a fever/sore throat/ a runny nose? -Do you have chills/ -Do you have night sweats? -Do you have shortness of breath/ chest pain? -Have you been wheezing? -Have you ever felt any lumps on your neck? Others -Do you feel fatigued? -Do you have abdominal pain? -Do you feel nauseated? -Do you have diarrhea? Are you constipated? Risk factors TB-Have you ever been exposed to TB? -Have you ever been tested for tuberculosis or PPD test? When was your last PPD result? What was its result? Sick contacts-Have you ever had sick contacts recently? Pets-Have you ever been exposed to animals? Do you have pets at home? Travel-Have you traveled recently? P.E. HEENT-ดุปาก คอ LN Chest- complete Dizziness(vertigo) DOPCSFAAA -What do you mean by the word dizziness? -Do you feel the room spinning around you? D-How long have you had this problem? -How long does it last per episode? O-Was the onset sudden or gradual? C-Is it constant? Or does it come and go?

S- F-How often do you feel dizzy? A-What makes it worse? A-What makes it better? Vertigo symptoms 1.vegetative NV-Do you feel nauseated? 2.Dizziness 3.Ataxia -Do you have any trouble with your balance? 4.nystagmus -Have you noticed any change in your vision? แยก peripheral/central position -Is it related to your position? -In what position makes it better/ worse? Eyes closure –Do you feel better when you close your eyes? Ears symptoms –HL- Do you have any difficulty hearing? Tinnitus-Do you have any ringing in your ears? Fullness-Do you feel fullness/pressure in your ears? D/C –Is there any discharge from your ears? Neuro.S&S- Do you have weakness/ numbness? -Do you have headaches? อาการอื&นๆ ของ labyrinthitis -Do you have a fever? -Do you have a runny nose/a sore throat/ a cough -Have you had any illness recently? -Have you ever had head trauma? P.E. HEENT-nystagmus, fundus, otoscopy,Hearing-Rinne/Weber, mouth, throat Neuro. –CN, motor, DTR/ gait, Romberg, tilt test(Dix-Hallpike), cerebrellar signs Headache DOPCSFLIQRAAA F-Does it come on at any particular time of the day? -Does it come on at the same time everyday? What time? -How long does it last per episode? I –Does it wake you up at night? -Does it affect your daily activities? Can you still perform your daily activities? Associated symptoms Migraine

Aura-Has there been any warnings that the headache is about to come like flashing lights before your eyes? N/V-Do you feel nauseated? Cluster HA Eyes symptoms -Have you noticed your eye turning red? -Do you have teary eyes? Runny nose-Have you had a runny nose during the attack? Organic brain Weakness/numbness-Do you have weakness/ numbness? Visual change- Have you noticed any change in your vision? Speech difficulties –Do you have speech difficulties? Subdural hematoma Head trauma- Have you ever had head trauma? Risk factors -Do you use birth control pills? -Does your symptom relate to menstruation? -Do you have any stress? -Is there something that’s worrying you? P.E. HEENT-palpation(head, facial sinuses, temporomandibular joints), fundus, nose, mouth, teeth, throat Neuro.-CN, motor power, DTRs Bloody urine DDx -Hematologic abnormalities -Infection -Trauma -Tumor -Exercise -Renal disorder -Stone

DOPCSFAAA -How do you know it was blood? -Do you have bleeding problems anywhere else in your body? -Has there been any change in your urinary habits? -Do you have pain or burning sensation during urination? -Are you going to the toilet more often? Or Do you have to urinate more often than usual? How often? -Have you noticed any change in the color of your urine? -Do you have to wake up at night to urinate? How often? -Do you have any difficulty urinating? -Do you have to strain or push during urination? -Have you noticed any weakness in your stream? Or Any dribbling of urine? -Do you feel as though you need to urinate but then very little urine comes out? -Do you feel that you haven’t completely emptied your bladder after urination? -Do you feel as though you have to urinate all the time? -Do you feel as though you have very little time to make it to the bathroom once you feel the urge to urinate?(urgency) -Has there been any discharge from your penis? -Do you have any pain in the back? P.E. ปกติ + CVA tenderness F/U HT Dx เมื$อไร -How long have you had high blood pressure? Tx อย่างไร -How have you been treated? Compliance -Do you take the medication regularly? Drug S.E. -Has there been any adverse effects from your medications?

Last doctor visit -When was the last time you visited your doctor? Or When was your last routine checkup? Eyes check -When was the last time you had your eyes checked? Monitor -How do you monitor your blood pressure? -What was the result of the last time? How is your blood pressure? -How do you feel today? Complications สมอง -Do you have headaches? -Do you have weakness/ numbness? -Do you feel dizzy? ใจ -Do you have chest pain? -Do you have heart racing? ไต -Have you noticed any change in your urination ANS -Have you noticed any change in your bowel movements? -Do you feel nauseated? Do you vomit? Any abdominal pain? ตา -Have you noticed any change in your vision? ตีน -Do you have foot ulcers? Sex -Do you have problems with sexual functions? -Do you have any problems with erection? -How is your sexual desire? อื#นๆ -Do you feel depressed? -Do you have any problems with your family or your job? -Please tell me about your diet. PMH ถามเป็นโรคๆ -Have you ever had high blood pressure/ high lipid level/ a stroke/ heart problems? Abdominal pain DOPCSFLIQRAAA -Which type of food makes the pain worse? Associated symptoms -N/V -a fever -change in your urinary habits -bowel movements change -mens, Vg. D/C, spotting, GYN. Hx.

Chest pain Associated symptoms -N/V -Dizziness -sweating -SOB -a fever -a cough -abdominal pain -wheezing P.E. HEENT-JVD, carotid Ext.-pulses, BP in both arms, edema Sore throat DOPCSFLIQRAAA Associated symptoms HEENT- URI-Do you have a cough? -Do you have a runny nose? Headache-Do you have headaches? Fever-Do you have a fever? -Do you have night sweats? Jx.-Have you noticed your eyes turning yellow? LN- Do you feel any lumps on your neck? - Is it painful? Chest-Do you have chest pain?

Abd.pain-Do you have abdominal pain? Others -Do you feel fatigued? -Do you have sick contacts? *STDs Hx.* -Are you sexually active? -Do you use condoms? Always? -Are you sexually active with men, women, or both? -How many sexual partners do you have? -How many sexual partners do you have in the past year? -Have you ever had a sexually transmitted disease? -Do you use any contraception? -Have you ever been tested for HIV? P.E. HEENT-nose, mouth, throat, LN, sinus tenderness Right arm pain DOPCSFLIQRAAA -Is there any events related to your symptom? -Tell me how it happened? -Do you have any weakness/numbness? -Do you lose your consciousness? -Do you have pain anywhere else? -Have you seen any doctors since then? -Why didn’t you seek medical attention? -Tell me about your likfe at home. -Have you ever been abused? -Do you feel safe at home? P.E. HEENT-bruises, neck movement Arms- ROM, strength both arms, shoulder, elbow, wrist, DTRs, pulses Fatigue DOPCSFAAA -How can I help you? -When did you first noticed? -Is there any events related to your symptom?or Have you had any recent traumatic events? P-How does it progress during the day? F-Do you feel fatigued at particular time of the day? Organic (TB, hypothyroid,DM,OSA,MG) -Have you noticed any change in your vision???? TB -Do you have a fever?

-Do you have night sweats? -Do you have shortness of breath? DM -Have you noticed any change in your urination? -Do you feel thirsty all the time? -Have you noticed any change in your bowel movement? -Do you have abdominal pain? OSA -Do you snore? Hypothyroidism -Do you have cold intolerance? -Have you noticed any change in your skin or hairs? -ถ้าเป็นผู้หญิงให้ถาม mense ด้วย Psychi -Do you feel depressed? -Do you feel guilty about anything? Do you have any problem falling asleep? Do you have any problem staying asleep? Do you have any problem waking up? Do you have difficulty concentrating? Have you ever thought about hurting yourself or ending of your life? Do you have any friends or family members you can talk to? ในกรณสีงสยั abuse Please tell me about that bruise? Have you ever been physically or emotionally abused? Are your children being abused? Do you feel safe at home? Does anyone in your family know about the abuse? Do you have emergency plan? Do you have a gun at home? Does your symptom effect your job? How is your appetite? Have you noticed any change in your weight? Challenging question 1. My father had pancreatic cancer. Could I have it too? Ans: It’s unlikely, but still one of our possibilities. So I need to run some tests for exclude this possibility. 2. My child is in the house alone. I must leave now. I can’t afford to stay in the hospital. Please give me a prescription for antibiotics sao that I can leave. Ans: We have to make sure that your illness is not serious. You have to stay in the hospital for observation. Our social worker can help you make sure your child is safe. 3. Doctor, do you think I will be able to move my arm again like before? Ans: I hope so, but we need to confirm the cause of this problem such as fracture, dislocation or nerve damage.

Closure: All right, Mr. xyz, thank you very much for your cooperation. First, let me SUMmarize the information. You have had _____ for at least the past six months and you also have had ____. Is that right?

And by physical examination which I found that ... I am considering a couple of possibilities. It may be __ (your probable diagnosis) or possibly __(differential diagnosis) or it may REPresent something more SErious such as ___.

I’d like to run some tests in ORder to make a diagNOsis.

This will inCLUDE the PELvic exam, blood tests, chest x-ray and more ADvanced test such as MRI, which is ____, may be NEcessary.

Your safety is my primary concern and I’m ready to help whenever you need it.

Have you ever considered moving to assisted-living community and apartment complex for seniors. If you are interested, I can arrange a meeting with our social worker, who can assess your social situation and help you.

Everything we discuss is confidential.

Do you have any QUEStions or conCERNs? 4. Do you think I have AIDS? Ans: That is a difficult question. First I need to find out why you are so concerned about AIDS. Do you think you are at risk? ** I also recommend that you avoid contact sports to prevent the risk of a ruptured spleen. 5. My father had colon cancer. Could I have it too? Ans: It is a possibility, because some type of colon cancer is hereditary. So I need to explore more by asking more questions and I will perform a physical exam and run some tests, then we can discuss more later. 6. Is it a heart attack? Am I going to die? Ans: I understand your concern because your symptoms may be serious. Please calm down, I need your cooperation to make a diagnosis. I will try my best to take care of your life. 7. Is my child going to be okay? Do you think I need to bring my child to the hospital? Ans: It’s very hard to assess your child by this conversation(or over telephone) so I would like you to bring him/her to the hospital, then I will perform physical exam and run some test here(at the hospital). Although I suspect that he has a viral infection, I still need to make sure that he does not have anything else.

8. Do you think I did the right thing by coming here and telling you about my child’s fever? Is my child going to be okay? Ans: You absolutely did the right thing. She may have an infection that needs antibiotics, so I would like you to bring him/her to the hospital, then I will perform physical exam and run some tests here. 9. Do I need to get antibiotics to get better? Ans: Maybe. Antibiotics can help in bacterial infection so I need to run some test to make a diagnosis, then we will discuss this topic. With your permission, I will run an HIV test. 10. Will I get better if I stop smoking? Ans: Stopping smoking should help your chronic cough, and over the long term it will decrease your risk of cancer 11. My father had pancreatic cancer. Could I have it too? Ans: That is one of our possibilities, Your family history does put you at slightly increased risk, but there are other explanations for your symptoms that we should rule out before making a diagnosis. Stop paracet+alcohol 12. Do you think I have Alzheimer’s disease? Ans: That is one of our possibilities. So I need to perform a physical exam and run some test, then we will discuss this topic. Closing All right, Mr. xyz, thank you very much for your cooperation. First, let me SUMmarize the information. You have had _____ for at least the past six months and you also have had ____. Is that right?

And by physical examination which I found that ... I am considering a couple of possibilities. It may be __ (your probable diagnosis) or possibly __(differential diagnosis) or it may REPresent something more SErious such as ___.

I’d like to run some tests in ORder to make a diagNOsis.

This will inCLUDE the PELvic exam, blood tests, chest x-ray and more ADvanced test such as MRI, which is ____, may be NEcessary

Due to your symptom, I would like to ask your permission to talk with your family because they can help me make a correct diagnosis and also the best treatment.

Moreover I would like you and your family to meet with social worker to assess your status at home and make safety recommendation.

The social worker will inform you of all community resources to help people in your situation.

I will remain in constant contact with you and your family to provide help and support. Do you have any question? 13. Will I lose my feet, doctor. Ans: No if we continue to keep your blood sugar well controlled. As long as you protect your feet from injury, everything will be OK. Closure OK. Mr.. thank you for your cooperation. -Mr. … from the result of you test, the blood sugar/blood pressure is …. And the aim of the blood sugar/blood pressure is ….. , so your result is higher than/within our goal. You must be careful about your diet. Try to limit fat, sugar and salt, increase fruit and vegetables and exercise is very important. It is importance to keep your blood sugar/blood pressure within normal limits. Persistently high blood sugar/blood pressure can cause damage to your eyes, kidneys, nerves, heart attack and stroke -Your symptoms (erectile problem) may be from diabetes. Better control of your blood sugar/blood pressure may improve this problem. -There are many explanation for your (erectile problem) such as…….., so we need to run some test to fine the problem. -Do you have any question? 14. No challenging question 15. I think that life is full of misery. Why do we have to live? I am afraid that I might have AIDS? Ans: You seem to be depressed. Would you like to share with me, what made you feel this way? OK. I understand you may not be ready, but I would like you to know if you need help,I will be here for you. Tell me more about your concern about AIDS. Closing … I would strongly recommend that you quit smoking, exercise regulary, and participate in activities that you find relaxing. I would also like you to promise me that if you feel like hurting yourself, you will call someone who can help you or go to an emergency department. 16. I am drinking a lot of water, doctor. What do you think the reason is? Ans: There are many explanations for your symptoms. So I need to run some tests before making a diagnosis. Once the results come back we can discuss more.

Closure

........... I am concerned about your safety and your relationship with your husband. I would

like you to know that I am available to you for help and support whenever you need it. I must involve child protective services if I have a reason to believe that your children are being abused.

I will bring back some telephone numbers and contact information for you regarding to where you can go for help if you or your children are in a crisis I suggest that you have emergency plan such as keep a back packed, so you can leave when you have a problem. 17. I want to go on a trip with my wife. Can we do the tests after I come back? Ans: I understand you dont’t want to miss the trip, but you may have a serious problem that may benefit from early diagnosis and treatment. Depressed patient SIG E CAPS Sleeping Interest (loss of interest) Guilty Energy Concentration Appetite Psychomotor agitation Suicide Closure ...... I can arrange a meeting with our social worker, who can help you find ways to cope with the stress. I suggest that you exercise and spend more time with family and friends. 18. Do you have anyhting that will make me feel better? Please, doctor, I am in pain. Ans: I know that you are in pain, but I need to determine the cause of the pain in order to give you the right treatment. So I need to explore more about the problem by asking you some question, perform physical exam and maybe run some tests. 19. They told me this (bloody urine) is because of my old age. Is that true? Ans: No. Bloody urine is rarely normal, so we need to explore more about this. 20. I think it (erectile dysfuntion) is my old age. Isn’t that right doctor? Ans: No, I don’t think because your age. There are many explantions for this problem such as medication or level of sex hormone. Mr. … from your result of blood sugar/blood pressure is …. And the aim of blood sugar/blood pressure is ….. , so your result is higher than/within our goal. You must be careful about your diet. Try to limit fat, sugar and salt, increase fruit and vegetable and exercise is very important. It is importance to keep your blood sugar/blood pressure within normal limits. I will change your medication with the other drug because propranolol can cause the problem.

I also need to perform a genital and a rectal exam. 21. Do you think I will be able to walk on my knee like before? Ans: I hope so, but that depends on the underlying problem and your response to treatment. 22. Do you think I will get better? (Tremor) Ans: I think your tremor will improve with medication, but that depends on the underlying problem and your response to treatment. I suspect that you have Parkinson’s disease which is the movement disorder, so I need to explore more about that possibility. Closure ….. One indicator of disease progression is change in handwriting. Could you please bring your old handwriting for me on the next visit? I will remain in constant contact with you and your family to provide help and support. Do you have any question? 23.Do you think I have a brain tumor? Ans: I think it’s unlikely, but to make sure we need to do a CAT scan, which is a special x-ray test of the brain. 24. I want to go back to smoking because I believe that I have started gaining weight since I quit. Ans: I understand that your weight is very important to you, but smoking can lead to many problems such as lung disease and cancer. (The benefits from smoking cessation outweighs the benefit from losing weight). We also need to determine what else might be contributing to your weight gain and then discuss about treatment options. (Quiting smoking is the lesser of two evils) You must be careful about your diet. Try to limit fat, sugar and salt, increase fruit and vegetable. An exercise program of only 30 minutes three times a week can improve your health. 25. Am I going through menopause? Ans: It’s unlikely. Although I want to make sure that your condition is not serious by performing physical exam and maybe run some tests. 26. Do you think I have a sexually transmitted disease? Ans: There are many explanations of vaginal discharge, one of them is sexually transmitted disease. I will try to explore more about your symptoms to get the correct diagnosis and also treatment. 27. I don’t think I can go to work, doctor. Can you write a letter to my boss so that I can have some days off?

Ans: sure, but I need to know the severity of your symptoms by performing a physical exam and maybe some test. Once I finish both of them, I will write the letter to your boss properly. Or You’re right, your job can worsen your symptoms. I will ask your boss to reassign you to light duty for a while. Or You’re right, your job can worsen your symptom. I will write the letter to your boss to let you have some days off. Or I know that you are uncomfortable, but after examining you I don’t find any disability significant enough to keep you out of work. I plan to prescribe a pain killer and exercises, but a big part of your recovery will be continuing your normal daily activities. 28. How sick is my baby? Ans: It’s very hard to assess your child over the telephone conversation so I would like you to bring him/her to the hospital for a physical examination and run some tests here. 29. Do you think I am going to deaf? Ans: I certainly hope not. According to your symptoms and by physical exam, you have some kind of hearing deficit. We need to perform more complicated tests to find the cause of the problems. 30. Did I do something wrong to cause this problem? Is my child going to get better? Ans: Bed-wetting is much more common than most people believe, there is no reason for you or your child to feel embarrassed or guilty. There are a number of treatment options for this condition. Once the test results come back, we will discuss them with you. 31. Do you think I am going to die? Ans: Your condition is obviously urgent. Pease calm down, I also need your cooperation to get the diagnosis. I will try my best to take care of you. We must observe you closely until you get better. Closure …. You should always seek medical treatment after an accident. Closing Summerize. All right, Mr. xyz, thank you very much for your cooperation.

First, let me SUMmarize the information. You have had _____ for at least the past six months and you also have had ____. Is that right?

And by physical examination which I found that ... I am considering a couple of possibilities. It may be __ (your probable diagnosis) or possibly __(differential diagnosis) or it may REPresent something more SErious such as ___.

Investigation

I’d like to run some tests in ORder to make a diagNOsis.

This will inCLUDE the PELvic exam, blood tests, chest x-ray and more ADvanced test such as MRI, which is ____, may be NEcessary.

Plan Once all the results come back, we will meet again. And we will disCUSS about the TREATment OPtions. Is that OK? -If it is a psychiatric case, like depression, grief, anxiety, or dementia, ask this question: Miss xyz, would you be willing to talk to a counselor or go to a support group?

-If Mr./Miss xyz smokes, drinks alcohol, eats fatty food, does not exercise, uses recreational drugs, has multiple sexual partners, does not use condoms, etc, give following suggestions:

• The patient with uncontrolled diabetes/HT o Your diabetes/HT is not adequately controlled according to your blood

glucose level/ blood pressure. § Poor compliant à you forgot to take your medication for many

times, we have a social worker who can arrange for a nurse to come to your home to help you. if you are interested .

§ Compliant à next question o You must be careful about your diet. Try to limit fat, sugar and salt,

increasefruit and vegetable. It is importance to keep your blood sugar/blood pressure within normal limits. Persistently high blood sugar/blood pressure can cause damage to your eyes,kidneys,nerves,heart attack and stroke.

o Fortunately, we have a diabetes/HT educator who may be able to help you. Are you interested in meeting with him?

• The alcoholic o I am concerned about your drinking. It can lead to liver disease, cause

the problems with bleeding, or early dementia. I strongly recommend you to quit drinking. And I would like you to know that if you are interested, I will be here for you.

o Are you interested in cutting down or quitting? § Yes à I am glad you want to quit. Let’s make an appointment later this week to talk

about your options. In the meantime, i have printed up a list of resources, and my office assistant will bring it to you.

§ No à I realize that you are not ready to quit, but I want to assure you that if you decide to try, I will be here for you. Okay?

• The smoker o I am concerned about your smoking. It can lead to lung disease,

cancer. I strongly recommend you to quit drinking. And I would like you to know that if you are interested, I will be here for you.

o Are you interested in quitting? § Response like the alcoholic

• The sexually promiscuous patient o I am concerned about your sexual habit. I suggest you to use condom

everytime to prevent you from STD, HIV and unwanted pregnancy. o With your permission, I will also test your blood for HIV. o You should tell your partner to visit doctor for treatment. (if ever had

STD) • Abuse

o Your safety is primary concern and I’m ready to help whenever you need it.

o Have you ever considered moving to assisted-living community or apartment complex for seniors? If you are interested, I can arrange a meeting with our social worker, who can assess your social situation and help you.

o Although everything we discuss is confidential.

• Child abuse o I must involve child protective services if I have a reason to believe

that your children are being abused. o I will bring ack some telephone numbers and contact information for

you regarding where you can go for help if you or your children are in a crisis.

• Forgetfullness o Due to your symptom, I would like to ask your permission to talk with

your family because they can help me get correct your diagnosis and also treatment

o Moreover I would like you and your family to meet with social worker to assess your status at home and have safety measure.

• Suicidal idea o If you feel like hurting yourself please call me immediately, I would

like you to promise that.

• Illicit drug o I know life may be stressful, but there are many solutions of the

problem, and trust me that drugs can’t never the answer of the problem.

Closure of pediatric -OK. Mrs. … from your information. I think that your child may have … because….

-It’s very hard to assess your child over the telephone conversation so I would like you to bring his/her to the hospital to physical examination and run some tests here. -Do you have any problem with transportation? -Yes à OK. I would like you to connect with social worker who will help this problem. -Do you have any question? Closure F/U -OK. Mr.. Thank you for your cooperation. -Mr. … from your result of blood sugar/blood pressure is …. And the aim of blood sugar/blood pressure is ….. , so your result is higher than/within our goal. I suggest you to chang your diet by decreasing salt, fat and sugar intake and increasing the amount of exercise you are doing. -Your symptoms (erectile problem) may be from … better control of your blood sugar/blood pressure may improve this problem. -There are many cause can describe your (erectile problem) …. Or there are many complications from your disease, so we need to run some test to fine the problem. -After we finish the test we will discuss together. -Do you have any question? Questions: Do you have any QUEStions or conCERNs? Farewell: Thank you very much and see you later. Bye! (Shake hand, firm grip) Challenging question -Do you think I have …. ?

• That is one of our possibilities, but there are other explanations for your symptoms that we should rule out before making a diagnosis.

• It’s unlikely: your symptoms are very unusual for pancreatic cancer. However we need to run some test to make a diagnosis and rule out cancer.

You must be really proud of yourself and if your dad could be here, he really proud of you too. Pronunciations Appear Associated Balance Confidential Contact Contain Continuous Contraceptive Cooperation Defecation

Embarrassed Episode Estimate Event Fatigued Flexibility Gown Hemorrhoids Hospitalize Injure Insert Intermittent Intolerance Libido Monitor Nausea Occur Possibility Preference Probably Problem Program Quantity Regain Regular Repeat Responsible Snore Temperature Urinary vigorous Did examinee knock on the door before entering the room? Did examinee appear professionally dressed and presentable? Did examinee introduce him/herself? Did examinee maintain comfortable eye contact? Did examinee use patient last name to address her/him? Did examinee have focused attention on patient? Did examinee express empathy? Did examinee convey nonjudgmental attitude? Did examinee use appropriate draping techniques? Did examinee use few open ended questions? Did examinee use non leading questions?

Did examinee ask multiple questions at a time? Did examinee question without interrupting the patient? Did examinee perform paraphrasing? Did examinee use layman language? Did examinee use transitional phrases? Did examinee give explanation during physical? Did examinee provide appropriate reassurance? Did examinee summarize significant history? Did examinee convey his diagnostic impression in layman terms? Did examinee discuss diagnostic test? Did examinee ask if patient had any questions or concerns? Did examinee offer patient education/suggestions? General patterns of Hx taking ****อย่ าลืม review of system คร่าวๆ ****

LODCRAFPT -Please show me eXACtly where your pain is. Location -When did it first start? Onset/ Duration +/-"Was all of sudden in onset or progressive?" -What is the pain like? Characteristic +/-"I mean is it crampy? sharp? throbbing? burning?" -." Is it constant?" or "Does it come and go?". Course

-if “come and go” à How often do you get this pain? Frequency

à How long does it last ? -Does it move anywhere? Radiation -Besides the , have you noticed anything else? How about ? Associated symptoms ควรถาม positive and negative symptoms เอง -What make it better? alleviating Factor -Anything make it worse? aggravating Factor -Has it changed over time? How? Progression +/-What might have brought this on? Precipitating factor -On a sCALE of 0-10, with 10 being the worst in your life, how would you describe

your pain? inTensity -Does it interFERE with your daily life? inTensity ในกรณขีอง intensity จะเ ลื อกข้อใดขึ- นกับ chief complaint เช่ น pain จะเลือก score แต่ถ้า shortness of breath ใช ้interfere

Associated problems:

Fever:

-"Do you have fever?"

• "How long have you had fever?" • "Is it continuous or intermittent?" • Is there any patterns to your fever? • What time of day do you have your fever? • Have you been shivering? Or Do you have chills? • Do you have sweats/night sweats?"

Cough:

• "Do you have a cough?" • "Is it a dry cough or productive cough?"

o If it is productive § "what color is it?" § "Is there any blood in it?" § "Is it foul smelling?" § "How much is it?" "Is it a tea spoon or table spoon or a

cupful?" • In all chronic cough patients don't forget to ask about HIV status and

tuberculosis. • You should also have to ask about drug intake especially about the use of ACE

inhibitors*.

Shortness of breath:

• "Have you ever had any problems with your breathing?" • "How far do you walk on level ground without having breathing problem?" • "Do you have to wake up at night short of breath?" (PND)

• "Have you been troubled with lying flat?". (orthopnea)

Nausea and vomiting:

• “ Do you feel nauseated?" • "Do you vomit ? "

o yes à "How many times? o What does the vomitus look like? o What color was it? o Was there any blood?"

• Ask the nature of vomiting like projectile etc.

Headache:

• "Do you have any headaches?"

Edema:

• "Have you noticed any swellings in your body?" o yes à" where did you first notice? o was it on the face or leg?"

• "Is the swelling more during morning or evening?"

Thyroid:

• "Have you ever had problems adjusting to temperatures?" • "Is there any change in your voice recently?" (hoarseness in hypothyroidism) • "Have you noticed any change in your bowel habits recently?" • " Have you noticed any change weight?”

Associated symptoms Shortness of breath 1. chest pain 2. cough 3. sweat Chest pain 1. dizziness 2. sweat 3. nauseated 4. shortness of breath Abdominal pain 1. nauseated 2. diarrhea 3. fever 4. urination change Past Medical History “Okay, Ms. Smith, now I need to ask about your health in GEneral.” P : Have you ever had SImilar PROblem beFORe? A : Do you have any allergies? M : Do you have any other MEDical conDItions? H : Have you ever been HOSpitalized before?

U : Have you noticed any changes in your uriNAtion? G : What about your bowel HAbits? S : Do you sleep well? F : “Ok Mr. Brown now I would like to ask few questions regarding (about) your family's health, Is that ok with you?” Does anyone in your FAmily have SImilar PROBlem? Are there any SErious MEdical conDItion in your family?

O : “Ok Mrs. Smith now I would like to ask few questions regarding your gynecological health, Is that ok with you?”,:

• If it is not a Obstetrical/Gynecological case just ask : 1. “When was your last menstrual period?”. 2. “Are your cycles regular?”.

If it is a OB/Gyn case enquire about

LMP, Regular?,Duration,pad,spotting,cramp,Preg,birth control, pap

• Menarche "How old were you when you had your first period?" or “When was your first period?”

• "Are your periods regular?" • "How many days does your period last?" • "Have you ever bleed between cycles?" • "How many pads do you use in a heavy day?" • "Do you have abdominal cramps/pain with your periods?" • "Did you ever notice any bleeding after intercourse?" • "When was your last menstrual period?” • Have you ever been PREGnant? How many times? Pregnancies • Have you ever had a misCARriage? Miscarriage • Any aBORtions? Abortion • Do you use any birth conTROL? Contraception" • Have you been getting regular pap smears?", • "When did you have the last Pap smear?".

S : “Now I’d like to ask you about your PERsonal life. It is very imPORtant to proVIDE you with PROper MEDical care. Everything you tell me will be kept confiDENtial.”

• Ms. Smith, are you SEXually ACtive? Sexual activity - yes, à With male, female, or both? Gender of partners

• Do you ALways use CONdoms? Condoms • How many SEXual PARTners have you had over the past year? Number of

partners • Have you ever had SEXually transMITted diSEASEs? STD • Have you ever been tested for HIV? HIV/AIDS • Do you have any PROblems with your SEXual FUNCtion? Sexual functions

S : “Ms. Smith, let’s talk about your SOcial life.”

OSARAWE or WADSADTOESH

• What type of work do you do ? Occupation • Is it STRESSful? Stress • Do you sMOKE? (if smokes) Smoking

o NO à“Have you ever smoked in the past?“ o YES à “How many packs per day? For how long?" o "Have you ever thought about quitting/attempted to quit?"

• Do you drink ALcohol? Alcohol

• If NO à “Have you ever consumed alcohol in the past?“ • If YES à

o “What type of beverage do you take? o How much do you drink per day? o "How long have you been drinking?"

• CAGE questionnaires for suspected alcohol abuse cases ( Ex. upper GI bleeding, Right upper quadrant pain, epigastric pain.)

• "Have you ever felt a need to cut down on drinking?" • "Have you ever felt annoyed by criticism of your drinking?" • "Have you ever had guilty feelings about your drinking?" • "Have you ever had a drink first thing in the morning to steady your

nerve ?"

• Do you use any ilicit drugs? Recreational drugs o If YES à

§ “What kind of drugs?", § "How long have you been taking them?” § "Have you ever injected drugs?"

• "How is your appetite?" Appetite • Have you noticed any change in your weight? Weight

o YESà “How much? In what period of time?” • "Do you exercise regularly?" exercise • Do you feel safe at home? Home

• ”What does your diet mainly consist?” Diet • "Have you traveled recently” "When?", "Where?". Travel

Special Situations:

Angry Patient:

• "Mr. xyz, you seem to be very angry, could you please tell me why that is so? Is there any way that I can help you."

Uncooperative patient:

• "Mr. XYZ I can understand your problem, but to properly understand your problem, I have to do this test. It won't take more than a minute. I am here to assist you. ok?"

Pain in hand:

• "Does your job involve repetitive hand movements like key board operation." (Carpal tunnel syndrome).

Insect bite:

• "Do you remember being bitten by any insects like ticks and mosquitoes?"( for any rash case)

Trauma patient:

• Some times you may get a patient with trauma or robbery etc. They will act like any thing and you can see all the bruises in different colors with good painting. The main issue with these patients is don't repeat the painful maneuvers. Some times they may worry about their social situation (money). For example a chest trauma patient from robbery who has signs and symptoms of hemothorax don't want to get chest -X -ray because he doesn't have insurance. So in those cases explain like this "We have a social worker and he/she will find out financial help for you."

• In the USA almost every hospital will have social worker to deal this kind of problems.

Over talkative patient:

• "Excuse me Mr. xyz, sorry to interrupt you. I know these things have really been bothering you. However I need to focus completely on you (or on your present situation).

• Some patients will respond normally but some patients will say "Are you interrupting me?". Don't worry they have been told to act like that. Say the same thing again and say sorry once again.

General:

• If you have to say “I don't know” say "I don't know yet".