All the info for CS - bobbynagpal

[ArchivalUser]

thanx a lot for all the help
heres the important points and notes which i copied from this forum only
just wanted to put back on this forum so that other can get all the info at one place
i hope it will help.......bobby14nagpal


buffycoat - 06/23/08 14:23

I am happy that you are getting something from this post.

Well about the tips I gave, may be the adminstrator is not pleased to post it......looks like it is been deleted....but somehow I could save the original copy and here it goes....................





I find it hard how to start the preparation. I was alone and new to this place. I was always finding myself difficult to speak up with the so called fluency with the people around me. As the days were near I panicked and thought that passing CS will be like a dream.
I looked in this forum and found the link to CS audio Kaplan courses. I suck it out and tried to listen to it. I started but left before it's all over.
For beginners like me, those audio holds good.
Meanwhile I started some pages from Usmleworld Books, but never finished more than 10 days. First aid was always my back up but I never used them. I tried www.csprotocol.blogspot.com and wrote the format of questions to be asked in my notebook but never reused it again.

Until late I joined some of the friends who have already grabbed the matter and knew the strategies to crack the exam. The first time I started the virtual case encounter, it was really discouraging for me .I was pathetic, but my friends consoled me that I will be in a good shape once I start practicing cases and utter relevant questions.
Then was the time that hit me that I lay in a verge of failing exam if I don't improve then. Next day in the practice, I asked all the history in the way I like and what I thought at the same time. Again I was told that I am not improving. I could figure out that I was not sincere enough to start the preparation.
Next day I took a day off from the practice and tried to go through the usual questions.
Then when I practiced in front of the mirror, I find out how difficult it is to ask the questions to patients being real calm and with empathy and important of all, on time.


The next day I went to practice, it was not that good but better than earlier.
2 cases and rest - never tried to write a patient note till then.
During our case practice we used to see both UW and FA cases and find out which one is missing what, after making an amalgam, we practice one by one the same case and comment upon one other's encounter.

Materials required “
Plain sheet of paper (in real exam of no importance because it is not evaluated)
Any ball point pen (Papermate brand black thick tipped-- in the real exam -2 in number)
Ideally should use a clip board (they use it in the real exam)
Timer/Stopwatch
Person who can simulate a patient (may not be a medical one, but should be a critic).
Has to cough if case is of cough, has to feel low if he has Depression, Has to itch if he has obstructive jaundice. Try this in every 1 in 5 encounter you do so that you won't miss out any.
Checklist and marking by the patient once the practice is going good.
Proper doorway information-Age, Sex, +/-Caucasian or white, complaints in patient's language (h/o passing out for unconsciousness, Pain in right side for Pyelonephritis) or ideal one (h/o cough, chest pain etc)
A table with length less than the usual bed to simulate patient's examination bed, as there is foot extensor in real patient's bed. Also know the real bed has drawer like area in the foot end of the bed to act as a step if patient has to step down to show you their gait. Use wood planks to simulate foot rest and foot extensor.
DO NOT TRY USING THE GLOVE EVEN IF YOU KNOW OR USED TO IT.Practice hand washing with proper technique”turn the water on and keep it on .Use the soap every time (push for it in the liquid soap case). Make sure you take your time cleaning nail area palm and dorsum. Now after you wash. Try to soak by 3-4 papers as one won't be enough, I know that. Then only with the wet paper on your hand you turn off the faucet/tap. Some faucet is left turn right turn separate type and some both in one type. I may sound silly explaining this minor stuffs but it will help you for sure ,so better learn earlier or else it will lower your confidence in your exam if you don't know how to close a tap.
And of all, DO LOOK AT THE PATIENT even if you have to twist yourself. Ask some question like-How have your mood been so far? Have you done your pap smear? Have you undergone colonoscopy? depending upon the patient. Make an ideal question the every time you wash your hands.
Alcoholic wipe, not mandatory but if time permits it can make patient happy as doctor is caring for their skin health.

A thin towel big size,folded simulating a drape and a chair should be present in every encounter.
A small room 7ft* 5ft with the bed near and facing parallel to the door entrance either to the left or right of the door.
Doorway information pasted on the door which can be flipped to view as the time starts for the encounter.
Objects simulating knee hammer, Tuning fork, otoscope, ophthalmoscope, switch nearby the patient's bed
Stethoscope
Lab coat worn opposite way to simulate a gown of the patient
Starting encounter with standard 'Examinee you may begin the encounter',

Sincerity not to look at the case unless the time starts, Giving a little time to stay out from the door to read patient information and to write Differential Diagnosis & PAMHUGSFOSS .In special condition which says-patient as diabetic write in the note DTR n fundus as you tend to forget to do in examination, MMSE if h/o feeling low.
DEATH n SHAFT if the patient has difficulty in remembering.

Starting an encounter:

'SP(standardized patients) be ready'”after 30 secs 'Examinee you may begin the encounter'
Go through the doorway information. Give some time to think “write age, sex, Last name of patient and remember that(you have to talk with them telling their name-practice with harder names e.g. Slaine, Brococh, Aubhaum)

Knock on the door 2-3 times and a pause, then get inside the room facing towards patient”be sure to tell morning / afternoon correctly. Good morning Mr. Slaine. I am doctor XYZ or Resident A and I will be seeing you today. Are you comfortable with the settings of the room? Let me make you make you more comfortable with this drape. (Sometimes patients get draped themselves, you just talk about the drape that's it)

(Simulate your feeling with the patient-eg Say you seem to be in great pain .I will be real quick and gentle with the examination. As soon as I get to know the cause, I will have my nurse give you the medication. Shall I proceed?) Next time they act to have pain, say the same with gentle touch over their shoulder or upper arm -never hands or back.
You will be surprised to see how they get well soon.

Donot shake the hand with the patient with shoulder pain.

Ask the pertinent history: Make sure you never miss OPD-Onset,Progression and Duration.
If complaint is pain “Ask all LIQOR AAA (location, quality, onset, and radiation,Aggravating,Alleviating factors,Associated factors)

Do not go on asking negative history eg: chest pain, cough, etc in a diabetic”even if the case is linked, ask quick questions.

Then ask about PAMHUGSFOSS”you should try to finish these questions in around 3 minutes maximum. So practice it harder. This roughly assess whether you will finish the conversation on time or not.

Focus on CIS (greeting patients,sorry to hear that,May I Is that ok with you n stuffs like that) and SEP (mainly effective counseling-try to utter few words but meaningful, you donot have to include everything so never be enthusiastic in that ,just attempt to give some most imp ones)
ICE consists of history taking and patient note “so if you missed out something also you can write that in patient™s note.

NEVER SAY I AM DONE ASKING-coz u might have missed something which you can ask later while u examine also.

Physical Examination:
Ask him/her that you are going to wash your hands.
Make sure you rub it to make it warm.
Begin with May I proceed?
Each time you donot have to say-there is no pallor,icterus etc. Just say that after you are done with it.
Neck-I cant see any visible veins or abnormal pulsation.
I want to take BP in both sitting n standing position, which I will do later.
Check pulses if case allows you.

Now I wud (no typos like that in exam) like to check your heart and lungs. For that I need to untie your gown, is that ok with you? Finish exam and tell let me tie back your gown.

Can you take a deep breath for me ?
Can you hold your breath for me “carotid bruit

Never be blank, do everything and let patient feel that you are doing something.

Shoulder pain/ leg pain “always say looks normal/abnormal when I compare.
No swelling, redness etc. Check the pulses, range of motion and sensation

Here US patients say pain and tender as somewhat same so you can ask for tenderness but when in doubt ask if it pains.

Abdomen-
I need to check your belly”do not say abdomen, they act like they don™t know or some even don™t know.
Can you please lie down for me? I will help you. Help them with the extension at the foot end to stretch their foot.
I need to adjust your gown to see your belly,
Is that ok with you?
Adjust it carefully.This is really difficult ,try a partner with only an underwear on and you will know how difficult will it be.
DO EVERYTHING SILLY BEFORE THE EXAM BUT NOT IN THE EXAM- any way some silliness happens but that should not feel you bad during whole of the exam.COZ 50% is what you need to pass-no one is excellent for 100%

Inspect-I can™t see any mass, redness or scars.
Auscultate- always the second step in abdomen ,no second thought ok.
Let me hear the bowel sounds.
Then palpate-do not just start.
Now I am going to feel your belly first gently then deeply-please let me know if you feel hurt or uncomfortable ok
Quickly touch all quadrants. Then deeply( not that deep-patients do not want you to poke him,the more gentle u r the less they are pissed off)
Now I am going to tap on your belly.Do single percussion on all quadrants.
Then say that you will do rectal/genital exam afterwards. BUT DO NOT DO just say only,you will get points for that.

CNS-start with MMSE if needed (in dementia,depression pts)
Then do cranial nerves- know 1 q for each cranial nerves.
Place the 5 fingers 1 feet in front-Can u count this? U will know if vision is normal or not.CN 2
Please move your eyes to follow my fingers,do not use your head
for CN 3,4,6
CN5-clench your teeth.close ur eyes and tell me whether you feel something on your face.
CN 7-smile for me. Frown for me.
CN 8- rub your thumb over index finger infront of both ears,Ask if they hear it equally.
CN 12-wiggle your tongue
CN 9 n 10 “say œahh
CN 11-Shrug your shoulder when I resist.


Power same way”first explain I will try to resist your movement..Then say kick outkick in
Push out /pull in
Check vibration in a diabetic.
Do the senses.
Do not ask I will do the jerk”say reflex”jerk means stupid in slang
Fundus-
I will dim the light and will shine a light in your eyes to see the back of your eyes-might be little uncomfortable but please bear with me .I will be quick.

Babinski-FIRST ASSURE. this might tingle you /make you uncomfortable .please bear with me for a while.I will be real quick

Otoscope”I am going to look in your ear.

After you are done with the examination let them sit.

From whatever you told me and the examination I did, I have certain probabilities in my mind (NEVER SAY YOU HAVE Pancreatitis/ Depression directly) You might be suffering from a condition in which your pancreas get inflammed-which is called pancreatitis.other possibilities may be ( state max. 2 possibilities)
In order to make it sure I need to run some blood tests-cholesterol,glucose,routine test etc, a graphical recording of your heart which is called EKG, picture of your heart which is called Echo”Do not let patient ask what is ECG or Echo.
Even if they ask be prepared to speak less and mean more.

IF A PATIENT SAYS I CANT UNDERSTAND-NEVER say those words again ,think of some other words to describe it.


After you told the diagnosis n say that will do some tests.
If he is a smoker/ /alcoholic“ counsel for stop smoking ,support groups available, let me know if you want to quit,
Depressed- want counselor to talk to? Support available for your care.

diabetic/hypertensive- be regular on your medications,exercise n life style modification, eye check up annually,check glucose n BP regularly.

Then:
I am happy that I was able to work with you .We will meet after the test results and will discuss on the treatment options ok. Shake hands and say bye.

GET OUT AS SOON AS YOUR TIME ENDS: Will c u later.shake hands n bye

Use stopwatch and set exact 10 mins or you can continue early if you finish encounter early. Print the sample patient note on usmle CD or you can use the First aid patient note section and the sample patient note there.
Use the paper with same width and length, in fact I practice with lining the paper first over the sample given in FA and print the same letters in same manner “ eg 10 line below .
History ten line gap then-- Physical examination---- D/D -----Investigations

Practice to write patient after every practice encounters “You will know how difficult will it be finish in 10 mins. So you will have to work on that how to finish in time.
Try the basic abbreviation only. You will get that in USMLE cd or in usmle.org




TRY N DO 2-3 encounters with patient note writing every day.


THIS MIGHT SEEM TO BE A MORE BOTTLE-FEEDING TYPE APPROACH but this is what the exam is all about”little clinical knowledge,be prepared for the worst condition,Tackle them with conscience and have patience---12 encounters to go.
Have a good food in between the break. Talk to other examinees in the starting before the exam, during the break”this will give you confidence to speak and you will never feel that you are doing bad.
Deal each encounter with the same happy mood.
Do not think over the bad encounters.
Positive vibes and confidence will only help you conquer this exam.



Hope this will help .
There may be typos but ignore them ok.
Any question you have ,I will try to clear it out.

Good Luck to all the CS givers..





How to Pass: We must pass all 3 components of exam in order to pass this exam
ICE “ Data gathering (40%) (History & Examination) & Patient note (60%)
CIS “ Cover 90% of what I have written in communication skills and you will be fine
SEP “ If SP understands what you are saying, you pass...

CIS:1. Knocked
2. Dress, Hygiene
3. Introduction
4. Eye contact
5. Attention & Concentration
6. Respectful & Non-judgmental
7. Draping
8. Transition
9. Empathy
10. Reassurance without interruption
11. Open ended question
12. Non-leading questions
13. One question at a time
14. Lay language
15. Listen & Paraphrased
16. Connected & purposeful
17. Summarized diagnostic plan
18. At ease / not alarming
19. Asked / Answered appropriately

HOW TO START: 1.First when u go and stand infront of the door...first clam ur nerves.when theres the announcement ....slide the cover...
step 1.read the complaint,recall ur mnemonic if u have one for that particular complaint{its excellent if u have one}

step 2.write down the pts name on the sheet they gave u..never ever forget that.

step 3.write the mneumonic next, pamhugsfoss,which systems u gonna examine{just key words like H for heart,R for respiratory,D.V. for deep veins..like that},lastly C for councel under which write SODA,and any other specific councel example..make it a rule for all lower abdomen cases and epigastric cases u will councel for a rectal exam,

For females any abdominal,mentrual complaints councel for pelvic,if abdominal like an epigastric or lower g.i. problem then the rule is RECTAL AND PELVIC for females.Indicate them by R for rectal,P for pelvic..since ur in a hurry inside the room u might forget to councel bout these,so if u have them written on ur sheet u will not forget it,just have a look at them after ur physical exam,to be sure u dont forget.


so now how ur rough sheet shud look..heres an example..

mr.jeff {use last name always}{SAY COMPLAINT IN SOB}

ur mneumonic

pamhugsfoss

P: H,R,D.V.{H for heart,R for respiratory,D.V. deep veins}

C:SODA[s for smoking,o for occupation,d for drugs,a for alcohol],specific counsel if any like take rest...

this will not take u more than 40sec.to write on ur sheet..follow this and i bet u will pass comfortably.

now u enter the room..first knock and open the door..as soon as u open it say ""hello there MR.JEFF" and enter{SMILE},next say good morning,nice to meet u...hope i got ur name right!!..

next introduce urself am DR.KHAN OR IRFANKHAN whatever,and i will be ur physician today.,,pause.

''please tell me how can i help u today''..he says he has sob..next u say..am so sorry to hear that,with a proper facial expression,not with a blank face..lol..and say well al do my best to make u feel better...ok!! now would u mind if i take down a few notes while we talk!! he says no its ok..u say thankyou..

next say ok now mr.jeff tell me something more bout ur problem...he tells u a few things..note them down,try not to repeat those..{it will come with practice}..next ask a the relevent questions related to differentials...NOT TOO MANY...just relevent....ask a bit detailed questions regarding the diagnosis for which he gives positive findings....once ur done with present hist.

come to pamhugsfoss..since u have written it in ur sheet u will not forget to ask...make sure u look at ur sheet now and then to make sure ur going accordingly....

Use patients name as much as possible and appropriate transition sentences{very important}..like here r a few..

1.mr.jeff now i would like to ask u a few questions regarding ur health in the past...correct

wrong: mr.jeff i would like to ask u regarding ur past medical history...see the difference.!!!

2.next r u allergic to any foods or drugs

3. do u take any medications{ important..if u dont understand the name ask him to spell it,if he cant spell ask him for what does he take it and if he does have the list}

4.have u had any accidents or injuries in past{ not trauma}

5.have u ever been hospitalised,any surgeries?{ as they can be even out pt.surgeries,like dental esp in heart case}

6.have u had any problems with urination,any problem with ur bowels

7.howz ur sleep and mood been lately..

8.ok.now mr.jeff now i would like to ask u a few questions regarding ur familys health..is that alright..?..try to avoid'' is that okay''..coz every fmg repeats it like a mechanical robot..u dont wanna do that..try to sound different and relate to them as a person..

9.now i would like to ask u a few personnel questions{not sexual hist}..and what ever u say will be confidential between u and me..alright?..remember when ever the sp gives u permission to ask never forget to say thankyou..!!!

for females always ask menstrual history..now heres the deal..if u have an ob/gyn case ask a detailed menst. hist,if its not..like a sob,respiratory..just ask these questions..in menst hist.

when was ur first period?

when was ur LMP?

r ur periods regular?


thats all..nothing else

when taking menstrual hist say...mrs smith now i would like to ask u bout ur menses..

if shes a post menopause just ask when was ur first period,when was ur LMP..thats it..done!

10.mr.jeff now i would like to ask u bout ur personnel habits and life style{not social hist}
then ask bout smoking,alcohol,drugs,diet,occupation,exercise,travel,apetite{just like in usmle world,think they have sumed up social hist very well in U.W.}..


after u finish asking hist..just say these MAGIC WORDS...''IS THERE ANYTHING ELSE THAT I NEED TO KNOW BOUT''......THE SP WILL BE LIKE '' UR RANK HAS JUST GONE UP IN MY BOOK SON!!!''....

if he says no..thats all..then say now i would like to do a physical exam on..ok!! smile..now if u excuse me for a min,,al just wash my hands...

P.E.: transition sentences very important here..say i would like to listen to ur heart,i would like to listen to ur chest,now i would like to listen to ur belly{not abdomen},now i would like to tap on ur chest or belly{ not percuss},now i would like to press on ur chest or belly{ not palpation}..when looking for tenderness look at the sps face!!! to look for any expression of pain...ALWAYS TELL THE PT. WHAT UR LOOKING FOR BEFORE DOING A PARTICULAR EXAM..

now heres the deal..students fail ..coz they do too much physical and no councelling...guys..spend less on physical and more on councelling it help u pass ur cis.very easily if u do a good closing..which fmgs often forget and end up failing in cis...heres the trick..heres a how to do a quick physical if ur short of time..DO THE MAIN SYSTEM CONCERNED IN DETAIL..FOR REMAINING SYSTEMS FOLLOW THIS...IF U R VERY SHORT OF TIME U CAN USE THIS EVEN FOR UR MAIN SYSTEM TOO...

MY QUICK PHYSICAL EXAM.....

œNow I am going to listen to your chest and back. May I untie your gown? [Cover transition
sentence for both CVS & RS]
Put stethoscope (2-3 sec only) in heart area and 3 areas on back for RS
œNow I am going to listen to your belly. Can you raise your gown?
Put stethoscope near belly button (umbilicus) for 2-3 sec only
œNow I am going to check your memory
Tell me your name. Where are we right now? What is today™s date?
œNow I am going to check your nerves. Just follow my finger and keep your head still
Move finger to make H “ checked 3, 4 & 6
Can you clinch your teeth like this? (Show how to clinch teeth) “ checked 5th motor
Can you raise your eyebrow? Can you show your teeth? “ Checked 7th
Can you open your mouth, stick out your tongue and say ˜Ah™? “ checked 9, 10, 12
œNow I am going to check power of your muscles
œSqueeze my fingers, pull me in “ checked motor in upper extremity
œKick out (put your hand at ankle of patient and asked to kick out) “ checked motor for lower
extremity
œNow I am going to check sensation of your body
Take cotton and tooth prick in your hand and show patient which is dull and which is sharp then
ask patient to close their eyes and check on face (5th sensory), check on tip of finger on hand (if
peripheral is ok then proximal is ok too so only check at finger tips. If no sensation at finger tips
then move upwards.) And same way check on toes.
œNow I am going to check reflexes of your body
Check Brachial and Patellar
œNow I would like you to walk here. I won™t let you fall [Be prepare. Patient should not be fall]


now when ur done with physical..next MOST IMPORTANT SUMMARIZE EVERYTHING...

OK..NOW MR.JEFF U JUST TOLD ME....BLA..BLA..BLA...IS THAT RIGHT..SP..SAYS YES..U SAY THANYOU...
next u say on physical exam i found ..ur findings..if normal..say..ur heart sounds good,belly sounds good,chest is clear..

next..say..from ur hist and physical what it appears to me is that u might be having some problem with ur heart or lungs{avoid big words like angina,MI,], even if the pt has g.i. cancer say there may be something wrong with ur bowel....

next say now i would like to run couple of tests on u..we will running some blood test{avoid words like cbc},we will take a picture of ur chest{not x ray},picture of ur belly..

for echo or doppler use the word sound wave picture !!!

if u have have to use words like colonoscopy or u.s. explain it to them..bout how u do it..say..we put a tube into ur bowel which has a camera on its tip..!!!! like that.

LASTLY COMES THE MOST IMPORTANT AND OFTEN NEGLECTED PART COUNSEL AND CLOSING..

councel bout SODA AND ANY SPECIFIC COUNCEL WHICH U WOULD LIKE TO GIVE...HERE R SOME...

if the pt is a old person or aged and lives alone always ask if he or she has some one to take care of him or her,if not ask if she or he would like to join an APARTMENT COMPLEX FOR ELDERLY..he will be like wow what a caring doc...make sure u have proper facial expression not a blank face when saying all these..forget hes am sp and treat him like ur mom or dad..u will pass easily....

lastly say do u have any questions for me? if he asks u..answer it and ask did i answer ur question?.....she will be like can i hug u!!!...

end up saying..al do my best to make u feel good!!..am available 24*7 ,if u have any questions and concerns just let me know..u take care..bye..have a nice day...!!!

PATIENTS NOTES VERY IMPORTANT..A GOOD NOTES MIGHT ALONE PASS U SOMETIMES EVEN IF U MISSED A FEW POINTS IN ASKING...

THERE R 2 STYLES 1.DESCRIPTIVE 2.BULLET

I USED BULLET STYLE..ITS MORE NEAT AND UNDERSTANDABLE,NO NEED FOR GRAMMAR..DO THIS..DIVIDE UR PT.NOTES SHEET INTO EXACTLY 2 HALVES ON ONE SIDE WRITE ..HPI..ON THE OTHER SIDE ROS,PMH,FH,SH,SEX.HIST...HERES AN EXAMPLE.


HPI: -PT C/O FEVER *4DAYS ROS
- PMH
- SH
- SEX


OR U CAN USE DESCRIPTIVE ON..BUT IF UR A BUSY PHYSICIAN WHICH ONE WUD U PREFER TO READ...!!!OUR PT.NOTES R CORRECTED BY PHYSICIANS..

NEXT HOW TO WRITE NORMAL PHYSICAL EXAM...PUT THE BEST DX FIRST IF U GET IT WRITE U GET AN EXTRA POINT!!! NOT THE SAME RULE FOR TESTS TO BE ORDERED THOUGH...INDICATE RECTAL OR PELVIC EXAM IN TESTS TO BE ORDERED IF INDICATED...

FIRST AID HAS PT.NOTES SAMPLES..THERE R EMPTY PT NOTES SAMPLE IN IT..GET A PHOTOCOPY OF THOSE AND PRACTICE ON THAT....

FINALLY PRACTICE WITH A PARTNER,NOT DUMMY'S..THERE R REAL PEOPLE IN EXAM..LOL..

REMEMBER...''GREAT PEOPLE DON'T DO DIFFERENT THINGS,THEY DO THINGS DIFFERENTLY''...

READ U.W. AND FIRST AID ...MORE THAN ENOUGH!! AND PRAY TO GOD...


CSA CASE PRESENTATION

CC: Chief complaint
ï‚– What caused you to come in today?

(LIQOR AAA)
Location
ï‚– Please point to the place where you feel the pain?

Intensity
ï‚– If 10 is the worst pain you've ever had, where would you put this on a scale of 1 to 10?

Quality
ï‚– Please describe the pain?
Amount
ï‚– How much _____ was there?
Color
ï‚– What color was it?
Consistency
ï‚– How thick was it?
Odor
ï‚– What did it smell like?
Blood
ï‚– Was there any blood in it?

Onset (DOCFP)
Duration
ï‚– How long did it last?
Onset
ï‚– When did this first start?
Course
ï‚– Has it changed any?
Frequency
ï‚– How often does this happen? Is it there all the time or off and on?
Precipitation
ï‚– What were you doing when this happened (started)?
ï‚– Was anything unusual happening in your life before this started?
ï‚– Are you aware of anything that may have brought this on?

Radiation
ï‚– Does the pain ever move anywhere else?
ï‚– Did it start there?
ï‚– Do you have pain anywhere else in your body?
Associated factors
ï‚– Besides chief complaint (your chest pain) have you noticed anything else, like _____? (sweating). How about _____? (vomiting). How about ______? (nausea).
Alleviating factors
ï‚– Did you try anything to make it better? Did that help?
Aggravating factors
ï‚– What makes it worse?

PAM HUGS FOSS
P (Previous episode)
ï‚– Have you ever had any ~(Pain) like this before?

A (Allergies) ADE
ï‚– Are you Allergic to anything? Any strange reaction to anything?
ï‚– How about to Drugs/Foods/Pets?
ï‚– Any changes in your living Environment?

M (Medication) Rx / OTC
ï‚– Rx: Are you taking any prescribed medications?
ï‚– OTC: How about over the counter products?

H (History of) THIS
ï‚– T (Trauma) Have you had any injury or accidents?
ï‚– H (Hospitalization) Have you ever been hospitalized?
ï‚– I (Illness) Have you had any serious illness or conditions, like _______?
¢ (High BP)? How about _____? (High Bld Sugar)?
ï‚– S (Surgeries) Have you ever had any surgeries?

U (Urinary)
ï‚– Have you noticed any changes in your urinary habits?

G (GI) Bm W NAVET
ï‚– Bm Have you noticed any changes in your bowel movements?
ï‚– W Any changes in your weight?
ï‚– N Did you feel nauseated?
ï‚– A Any changes in your appetite?
ï‚– V Did you vomit?
ï‚– E What do you usually eat? Any changes in your eating habits?
ï‚– T Have you been traveling lately?

S (Sleep)
ï‚– Have there been any changes in your sleeping habits?

F (Family) SRO
ï‚– S (Same of similar) Anyone in your family have the same thing? (a similar experience)

ï‚– R (Related) Anyone in your family have high blood pressure, Diabetes, High
Cholesterol, Stroke?
ï‚– O (Other) Any other serious illness or condition in your family?

O (Ob/Gyn) G PARLS Bc

ï‚– G (Gravida) Have you ever been pregnant? How many times?
ï‚– P (Parity) How many times have you given birth?
ï‚– A (Abortion) Have you ever had an abortion or miscarriage?
ï‚– L (LMP) When was your last menstrual period?
ï‚– R (Regular) Is it regular?
ï‚– S (Spotting) Do you ever notice any spotting? (Break through bleeding)
ï‚– Bc (Birth control) Do you ever use any method of birth control?

S (Sexual) G SCAN
ï‚– G (Gender) Are your sexual partners male, female or both?
ï‚– S (STD) Have you ever had a sexually transmitted disease?
ï‚– C (Condoms) Do you use condoms consistently?
ï‚– A (Active) Are you currently sexually active? Have you ever been sexually active?
ï‚– N (Number) How many sexual partners have you had in the past six months?

S (Social) TADER Works at Home
ï‚– T (Tobacco) Have you ever used Tobacco?
ï‚– A (Alcohol) Do you drink alcohol?
ï‚– D (Drug) Do you ever use recreational drugs?
ï‚– E (Exercise) Do you exercise regularly?
ï‚– R (Routine) Tell me about your daily routine?
ï‚– W (Work) Tell me about your work situation?
ï‚– H (Home) Please describe your home life?


Urinary System
1) Can you feel that you want to pass urine?
2) Can you hold when you want to pass urine?
3) Do you ever feel that you must pass urine immediately & rush to the bathroom?
4) Do you have any difficulty in starting the flow of urine?
5) How would you describe your urine flow?
6) Do you have any pain during urination?
7) How does your bladder feel after you passed urine?
8) Urine- amount, color, blood. How often do you pass urine at night? What color is it? Was there any blood in urine?
9) Discharge from your urinary tract Have you noticed any discharge?
10) Have you ever been running a fever?
11) Have you ever had any pain in you back?

Pain (Empathy)
1) I know you are in pain. ------ This exam is really important & it will help me understand what is causing the pain & to give u the right treatment ASAP.
2) I do understand that you are in pain. Let me help you and I will be fast & thorough. These are really important in finding out what™s going on. I will tell you what I am going to do before I do it.
3) You seem to be experiencing a lot of pain right now. Let me help you to change your position to feel more comfortable?

Help (counseling)
1) Would you like to talk over with a counselor?
2) Would you be willing to let a counselor help you work through this problem?
3) There are several good support groups in the community. Would you like to have this kind of peer support?
4) A good counselor can help you through this difficult time. Would you like a list of professionals in the local area?
5) I just want you to know you're not alone. There are people ready to help you make it through this. I can get a list of phone numbers you can call if you need help.
Thyroid
1) Do you often get constipation?
2) Has your skin been dry lately?
3) Have you been loosing your hair?
4) Does cold or hot temperature ever bother you very badly?
5) Do you trouble sleeping?

Pt: It's only indigestion. I don't know why you are so worried about my heart.
Doc: That's one possibility, but I'd like to check some other possibilities as well. There are many conditions that can cause like this ~ (Pain).

Mr. ------- I can imagine that is very ~ (frightening). Let me reassure you that I will find out what you have. I will be very thorough & careful in getting you the right treatment as soon as possible.

Gynecology
1) How old were you when you had your first period?
2) Do you have a period every month? (Is it regular?)
3) When was your 1st day of last menstrual period?
4) How many days are in your cycle?
5) Has your period changed in anyway?
6) Do you have cramps?
7) On a heavy day, how many pads or tampons do you use?
8) Do you have any problems with the PMS?
9) Have you ever been pregnant? How many times?
10) How many times have you given birth?
11) Have you ever had a miscarriage or abortion? (If miscarried, in what trimester?)
12) Do you ever notice any spotting?



Pediatrics
Birth History
1) Was the pregnancy full term? (40 weeks, or 9 months)
2) Did the mother have routine prenatal checkups? How often?
3) Was a sonogram or amniocentesis performed during the pregnancy?
4) Were there any problems with the pregnancy like high BP, high bld sugar, vaginal bleed?
5) Did the mother smoke, drink or use drugs during the pregnancy?
6) Was it a normal, uncomplicated, vaginal delivery?
7) What were the child's Apgar scores?
8) Did the child have any medical problems when he or she was born?
9) The child's first bowel movement was within how many hours?
10) The child's first urination was within how many hours?
11) Mother and child left the hospital after how long?
Developmental Milestones
1) Is the child's current height and weight following the growth curve?
2) First smile when?
3) First sat up when?
4) Started crawling when?
5) Started walking when?
6) Started putting short sentences together when?
7) Putting things in mouth?
Feeding History
1) Was the child breast fed or given formula?
2) Started eating solid food when? (How old was he or she when you started him or her on solid food?)
3) Eats and likes what foods now?
4) How is the child's appetite?
5) Does the child take a daily pediatric multivitamin?
6) Does the child have any allergies?
Routine Care
1) Name of pediatrician and clinic where child is routinely seen?
2) Up to date on immunizations? (Hepatitis, DPT, Polio "series shot"; MMR)
3) Last routine checkup date? (When was the child's routine checkup?)
4) Has the child ever been hospitalized?
5) Any serious illness?
6) Any medications?
"Ms. Smith, I need to be very systematic and careful. So let's take one step at a time.
First, I need to run some blood and urine tests and some x rays.
Then, after I study the results, I will be able to give you a definite diagnosis and your options for treatment. At that time, we will sit down together and go over everything in detail. Okay"

(Transition)
All right, Mr. Cooper. Now, let me sit down and talk over what I think so far.
First, let me summarize.
You said that ____ and ____: Also you told me that ______and _____. Is that right? Your sister and mother have both been treated for _________. In the Physical exam, I observed that __________ and ________.
"I believe that this may involve your ________. (name organ or body system) I'm considering a couple of possibilities. Most likely, it may be ______."(give your diagnostic impression) Now, ______is _____. ______ is ______. (Explain what these disease conditions are in lay terms.)
"I need to have some blood, urine tests and x rays. As soon as I study the results, let's meet again to go over everything. At that time, I'll explain the details and we'll talk about your options for treatment. Okay?
(If it is a psychiatric case, like depression, grief, anxiety, or dementia, also ask if the patient would be willing to talk to a counselor or go to a support group)
Mr. , Do you have any concern or questions you'd like to ask before I go?
(Answer the question briefly, simply, and reassuringly.)
Well then, I'm very grateful that I'll be able to work with you, Mr. /.. Thank you for coming in. I want to reassure you that I'll be very careful and through in helping you. (shake the pt. hand)
Bye for now. Take car.

Recovery Strategies
Doc: I see you're wearing an ace bandage on your wrist. What happened there?
Pt: Oh, I hurt my wrist playing tennis yesterday.
Doc: Nodding, "Playing tennis."

Doc: I see you're wearing an ace bandage on your wrist. What happened there?
Pt: Oh, I hurt my wrist playing pool yesterday.
Doc: Nodding. "While you are playing polo?"
Pt: No, no playing pool.
Doc Oh, Okay. "Playing pool."




Doc: Have you had any change in your weight recently? - Pt: Yeah, I've lost about 7 to 8 pounds.
Doc: Over what period of time? - Pt: Let's see-over about the past 2 months.
Doc: So, for the past couple of months, you've lost about 7 or 8 pounds.

Doc: Have you had any change in your weight recently?
Pt: Yeah, I must've lost about 7 to 8 pounds.
Doc: Over what period of time?
Pt: About 2 months.
Doc: So You've lost about 7 or 8 pounds over the past 2 weeks.
Pt: No, not 2 weeks; it's been about 2 months.
Doc: Oh-2 months. All right.

TRANSITION
Before asking the past medical history
Okay, Mr. Green, now I'm going to ask you some question about your health in general that might help finding the problem.

Before asking sexual history.
Now I need to ask you some important questions about your personal habits so that I may understand your health in general. Whatever you tell me will be kept confidential.

Before the social history.
Thank you. Now let me ask you about your work, family and social life.

Before asking questions about smoking, alcohol, and social life.
Okay, now I need to get some information about your lifestyle.

Before the family history
Now let's talk about your family's health.

Before the physical examination
All right, thanks for answering all these questions. Now I'll need to examine you. So I'll just wash my hands. Excuse me. Okay, Mr. Green, let's begin by _________

During physical examination
Now, I need to look in your throat to see if there's any redness or swelling.

Before the closing
Okay then, thanks for your cooperation. Now I'd like to sit down and talk over what I think so far.

First let me summarize
In addition to your headache, have you noticed anything else? (eg. nausea, vomiting, cough, fever, dizziness, cold, sore throat, weakness in your legs, tingling sensation, burning sensation, numbness, sweating)

Did or do you feel nauseated?
or
Have you been nauseated?
Did you feel sick to your stomach?

Did you vomit?
or
Did you throw up?
Have you been vomiting?
And:
What was in it?
What color was it?
Was there any blood in it?
How much was there?

When you cough, does anything come up?
or
Do you ever spit (cough) anything up?
And:
What color is it?
Is there any blood in it?
How much phlegm comes up: teaspoon? table spoon? cupful?

Have you been having headache?
or
Do you get headache?
And:
Where are your headaches?
How intense (painful) are they on a scale from 1 to 10 (10 being the worst)?
When did they start?
How often do you get a headache?
What are you doing when the headache comes on?

Have you been running a fever?
or
Have you been feeling hotter (warmer) than usual?
And:
Do you sweat a lot during the night?

Do you get short of breath?
or
Do you ever feel out of breath?
And:
Have you been wheezing?

Have you had any changes in your urinary habits?

Have you had any changes in your bowel habits?
And:
When you go to the bathroom, what does your stool like; hard or soft or loose?
What color is it?
Was it very foul smelling?
Does it float?
Have you been having diarrhea?
How long have you had the diarrhea?
Have you been constipated?
How many bowel movements do you have per day?
Have you had any recent weight change?
Do you get stomach cramps?

Has your weight changed any?
And:
Over what period of time?

Has your diet changed in any way?
or
Have you changed your eating habit?
What do you usually eat?
Did you eat anything unusual?
What did you eat right before the nausea started?

Has your sleep pattern changed in any way?
D™u have any problem in going and staying asleep?
Any problem in waking up?

Have there been any changes in your vision?
Or
Has your eyesight changed in any way?
Any problem in looking at lights?

Do you ever feel dizzy?
Have u been feeling the room spinning around u?
or
Do you have black out sensation?

Do you have joint pain anywhere in your body?
Or
Do you have pain in any other joints?

Have there been any changes in your environment lately?

Have you been traveling anywhere lately?








PMH (PAMHUGS)
P
A ADE
M Rx Otc
H THIS
U
G BmW NAVET
S
FH SRO
Ob/gyn H GPALRS Bc
Sx H GSCAN
S H TADER W H
CASE
1) Pain
a. Up abd pain (cholecystitis)
b. Chest pain (Angina)
c. Abdominal pain (Appendicitis)
d. Headache
e. Joint pain
1. TMJ jt pain
2. Shoulder pain
3. Back ache
4. wrist pain
5. knee pain
2) Diarrhea and abd pain
3) Acute Cough with chest pain (smoker)
4) Chronic cough (multiple sex partner)
5) Breathing difficulty
6) Anxiety
7) Neck stiffness and head ache

Case scenario
1) Lower abd pain (appendicitis)
2) Heart beating so fast (palpitation)
3) Nausea and fatigue (intrauterine pregnancy)
4) Difficulty in walking (Parkinson)
5) Acute onset diarrhea in a child (Failure to thrive)
6) No energy (Diabetes, Diabetes insipidus or Psychogenic water intake, Anemia, Hypothyroid)
7) Fatigue (hypothyroid)
8) Retching and vomiting blood
9) Shortness of breath (Congestive heart failure)
10) Headache, running nose and abd pain (Cocaine addition)
11) Problem sleeping at night

Special cases
Parkinson Dementia Hypertension (refill)
Sickle cell disease Obesity Weight loss
Domestic abuse Ob/gyn Pediatrics case
Giving bad news Impotence

Psychiatric History
Mini Mental Status Examination
Do in pt who is hearing voices, or seeing things during the encounter and if you get positive responses to questions about hallucination, and concentration/memory impairment.
Say "I'd like to check your memory and concentration by asking you to do a few things now"
Appearance, Alert, Orientation, Speech
Recent and remote memory, Attention/concentration, Memory, Affect
Perception (Hallucination/delusion/paranoia, Suicidal/homicidal ideation, Judgment/insight)

Special aspect
Past psych Hx
Med/ drugs/ alcohol
Family psych Hx
Social Hx

Psych mental status
A appearance
C consciousness
O orientation
S speech
B recent and remote memory
A attention and concentration
M mood
A affect
P perception (hallucination, delusion, paranoia)
S suicidal/homicidal ideation
J judgment/insight


Psychiatric Q: FAWSIM FSH ADH TSH
How have you been feeling lately?

Source of unhappiness (anxiety, frustration, feeling, mood change)
Do you have any idea of what is causing your unhappiness? (sadness, confusion)
Would you be willing to share with me what happen that made you feel this way?

Support System
Do you have anyone you can talk to whenever u are in a stressful situation?
Do you have any friends or family members you relate to?
Is there anyone there for you when you need them?

Appetite
Has your appetite changed any?
Do you feel like eating?
Have your eating habits changed any?

Weight
Has your weight changed any?

Caffeine
How's your caffeine intake?
R U taking/ Do you have ----- a lot of coffee, colas, tea, or chocolate?

Daily routine
Has your daily routine changed any?
What do you usually do with your time?


Sleep pattern
Is your sleep affected by this?
Have your sleeping patterns (habits) changed in any way?
Interests/activities
What kind of interests/activities do you have?
What activities are you involved in?
Have your interests/activities changed at all?
Do you feel any pleasure from the things you're involved in?
Concentration (memory)
How's your concentration (memory)?
Are you having any difficulty concentration? (remembering things)
Do you lose things more often?
Duration of affect
How long have you been feeling this way?
Optimism/Pessimism
Do you have any plans for the future?
What are your plans for the future?
Would you say you usually feel optimistic or pessimistic?
Do you think things will get any better?
Ideation of suicide or self inflicted pain
Do you ever consider taking your own life?
Do you ever imagine ending your life?
Do you ever think about killing yourself?
Do you ever feel like ending it all?
Do you ever feel tempted to take your life?
Do you think you might want to kill yourself?
Suicidal plan
Do you actually have a plan?
Would you be willing to tell me what it is?
Do you already have the gun (pills)?
Abuse
Are you in any danger from anyone in your personal life?
Tell me about your home life?
Do feel safe at home (in your relationship)
Do your parents (boy friend/ girlfriend, roommate, husband/wife) treat you badly?
How's your relationship with your parents (for example)?
You're wearing an ace bandage on your wrist. Can you tell me about that?
Were you harmed repeatedly by anyone during childhood?
Were you left alone often?
Does anyone repeatedly call you names or put you down?
Harming others
Do you ever feel like hurting anyone?
Hallucinations
Sometimes, people are under a lot of stress, they see or hear things that others don't. Does this ever happen to you?
Do people ever tell you they think you are hearing or seeing things that others don™t?
Delusion
Do people ever tell you they think you have extremely unrealistic idea about yourself or about life in general?
Thyroid
Do you often get constipated?
Has your skin been really dry lately?
Have you been losing your hair? (Has you hair been falling out?)
Does cold or hot temperature ever bother you very badly?
Do you have trouble sleeping?
Family history
Has anyone in your family ever had problems with feeling low or extremely discouraged in life?
Does anyone in your family have problems with concentration or clear thinking?
Willingness to seek help
Would you like to talk things over with a counselor?
Would you be willing to let a counselor help you work through this problem?
There are several good support groups in the community. Would you like to have this kind of peer support?
A good counselor can help you through this difficult time. Would you like a list of professionals in the local area?
I just want you to know you're not alone. There are people ready to help you make it through this. I can get a list of phone # you can call if you need help.

Closing
1) Briefly summarize
2) Brief explain your D/D
3) Explain Tests
4) Reserve management discussion (until we are sure what the problem is)
5) Avoid alarming the patient
6) Ask if the patient has any question
7) Thank the patient for coming
8) Reassure the patient that you will be careful and will do everything you can to help
9) Shake the pt's hand and say take care.
10) Leave the room
D/D
Adjustment disorder
Drug/alcohol use
Med side effects (?)
Delirium
Dementia
Acute confusional state
Brief psychotic reaction
Bipolar Disorder (Manic or depress episode)
Unipolar major depression
Underlying medical disorder
SLE, HIV, PHEOCHROMOCYTOMA, THYROID, DM, INFECTION, Brain tumor
Work up
CT or MRI brain
TSH, T3 and T4
Drug screen
Electrolytes, Vitamin B12 and Folate
Urine for Catecholamine, VMA
HIV Elisa, RPR

32 female multiple bruises

(Think about
accident
physical assult
spousal abuse
bleeding disorder
collagen vascular disorder)

I am told u r here to check for some injuries, would u like to tell me how were you hurt?
What happened? Do u have any other injuries ?

To Husband-I would like to examine her alone Do u mind to leave the room

"I notice you have a number of bruises. Did some one do this to you? It looks like some one hurt you. it does not look like being caused from a fall Can you please tell me what happened to you?"
I do not know this may be a problem with you or not but we are seeing so many patients suffering from abusive relationships that we have now started ask about this to every patient in our clinic. Whatever you say will be kept confidential between you and me and nobody can access your medical records without your signed consent.

are u in any such type of abusive relationship??"

"I can understand that you may not be comfortable to discuss about this but as your concerned physician your safety and your health is my first priority. i want to help you to deal with it but for that i need your help to. Would you like to share it with me ??

Does he hit u everyday Has it ever happened before? How many times? Are you afraid it will happen again? does anything initiates his behavior or What initiates it? Can u describe what u mean by this rage episode. Does he hit u in front of children too?




SAFEGARDS
S Do u feel safe at home Do u feel emotionally numb or helpless or deserve to be hurt or mistreated?
A R u afraid of your husband? " Did u ever feel that he might kill u / how many times humiliate, criticize, or yell at you? treat you so badly that you™re embarrassed for your friends or family to see? ignore or put down your opinions or accomplishments? blame you for his own abusive behavior? see you as property or a sex object, rather than as a person?

Why didn™t u leave him? Why is it difficult to leave him? Has he threaten to take your children away or harm them? Does he threaten to suicide if u leave him?
F Where do your parents or other family member any friend live close by? Do they know about your situation?
E "Do you have an emergency plan to leave home if need arises
G Is there any weapon at home. Has a weapon ever been used in an attack on you?" do u think your husband might use it?
A Does he drink? have a bad and unpredictable temper?

R how long have u been married You have mentioned your partner looses his temper with you. How are things between him and your children?" "Have you ever left home? When? if not, have you wished to leave? What has prevented it?" "Are you planning to leave/divorce your partner?" "Has your partner ever threatened or tried to commit suicide?" "Do you, yourself, think of suicide as a way out of the relationship?" If the answer is 'yes' ask "Do you have a plan or method by which you would kill yourself? or partner?" ""How long have you been in this abusive relationship? Do u feel that your husband loves u/ act excessively jealous and possessive? control where you go or what you do? keep you from seeing your friends or family? limit your access to money, the phone, or the car? constantly check up on you? Does he ever yell, name-call, blam, and shame you in front of anyone? love them or not ? plan to give divorce
D Does your partner use any type of recreational drugs?"
S Has your partner ever made you have sex when you didn't want to?"

Reporting case to agency--- Did u ever reported the matter to any agency do u wish to report matter t o agency?"
Children--" How many children do u have? How old are they? How is their relation with your husband? Has he ever hit them/ do u feel they feel safe to go near him?Are the children being abused or threatened?

Add- depression face slip



Occupation--What does your husband do? Does he drink? What work do u do?

How is your sexual relationship with him? Do u have other sexual partner
Do u smoke do u drink r u taking any recreational drug?
Moving on to family history “Do anyone in family have bleeding disorders
Medical history”R u taking any medications


.

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

diagnosis
spousal abuse with broken upper arm


investigation
CBC
X-ray to rule out a fracture

Closure and counseling

I have every reason to believe you are victim of domestic violence. I am concerned about your safety and your relationship with your husband. No one deserve to be beaten. Battering is against the law. I would like u to know that I am available to u for help and suport whenever u need it. Everything discussed here today will be confidential. I must involve child pretection services If I have reason to believe that your children are being abused. I can give u some numbers and contact information for u regarding where u can go for help in a crisis. Or if ujust want to talk.

First thing u need to realize is it is not your fault, you are not crazy and you are not alone, help is available for you if you want.

I would like to assure u that your medical condition will be treated appropriately, and u will not be forced to do anything against your will.

I want u to now 2 Worst thing about domestic violence

First. these types of episodes generally increase in severity and frequency and it is never going to end, although he will say I'm sorry for hurting you and will not hurt her again. Your abuser™s apologies and loving gestures in between the episodes of abuse can make it difficult to leave. He may make you believe that you are the only person who can help him, that things will be different this time, and that he truly loves you. However, the dangers of staying are real. only way to end abuse is to get away from batter

Second - its effect on children. Have you thought about its effect on children? They may not be at physical danger but the emotional and psychological consequences of domestic abuse are severe. Children may experience some of the same trauma as abused children. Not all children are affected by domestic violence in the same way

Some children may become fearful, inhibited, withdrawn, anxious, depressed and others becomes aggressive, antisocial, , angry, confused;
Many times they suffer from disturbed sleep, problems with eating, difficulties at school and challenges in making friends.
Children often feel caught in the middle between their parents and find it difficult to talk to either of them. Children may injured if they try to intervene in the violence in their homes
Adolescents may act out or exhibit risk-taking behaviors such as drug and alcohol use, running away, sexual promiscuity and criminal behavior.
Young men may try to protect their mothers, or they may become abusive to their mothers themselves.
.

I can understand it is not easy to simply leave your homes, jobs, children™s schools, your friends, and your relatives to escape. you may believe that it's easier to stay with your abuser than to try to leave and risk retaliation. However, there are many things you can do to protect yourself while getting out of an abusive situation, and there are people waiting to help.

If u decide not to go back today, we have places and social workers to help u right away. If you are worried about your children, I would like you to know that your children will be cared for and I will make sure they are safe.

Even if u decide not to leave your husband and want to go back to home now , I would like u to know some things. We have excellent team of counselor if u r interested to talk.
There are many social welfare agencies to help people like in you and support groups in the community. Do u want their address or phone number?


If u are not ready to act now, I highly recommend u to create a safety plan (Packing some clothes, utilities and money that would last you a week and leaving the suitcase in a fiend™s house), so you know exactly where to go and how to get away fast when your husband attacks and when u want to leave. Know some emergency numbers in case of need.

I would like u to take my office phone number u can call me anytime. My primary concern is your safety and I™m always available to help you in this regardno matter what your decision is. I will do everything possible to maintain your safety.

Ok! thanks for seeing me! We will meet again when lab result comes or whenever u want me to.

elder abuse

What is your hobby
Do you do the same activities you used to do like going to visit other friends, clubs
How many childrens do u have
Do u have any other families near by
Do u visit other children or families why not? Does your son get angry if u talk to them in his absence
are you being treated well at home?' does your family help you with your basic needs? (if pt needs help like taking meds, going to the wash room, bathing etc)

Tell me something about your life at home? How is your relation with your son?
Is there frequent argument and tension between u and your son.
Does your son yell at you, humiliate you.
R U Frightened to talk to anyone without your son™s approval
Does he blame you if anything goes wrong at home or his work
Do u feel helpless or angry
Does he misuse your personal check creditcard or accounts.

Do u blame yourself for his behaviour?
Do u feel If I™d been a better parent when they were younger, this wouldn™t be happening.

do u feel safe at home?'

If you are unhappy with the care you™re receiving speak up. Tell someone you trust and ask for help person I know it is very hard to tell anyone about your son,
I want to tell you, don™t be ashamed or blame yourself, It is not your fault he behaves that way.
I also want u to know there is help awaiting for u
Don™t think there will be no one who will take care of them if u leave your son™s home . there are many places where u can go, There are people to help you. I am here to help u. don™t fear retaliation from your son or anyone.

Have u ever considered moving to an assisted living community or to an apartment complex for senior. Sometimes living with family is stressful for the whole household. Your safety is my primary concern . If u are interested I can arrange a meeting with social worker who can asses your situation and help u find the resources you need . that might be something good for your if your not happy at home.

Child with Jaundice:

When did you first notice?
You said u noticed yellowness in eye, is only eye yellow or face also? How about chest, abdomen, and leg?
Sometimes light also gives false impression of yellowness Did u examine your baby in natural daylight?
Does the Skin appear deep yellow or orange?
Is he Vomiting?
Did u notice any Distension of abdomen?

How old is your child? How is it progressing now-Getting worse or constant ?
Is your child awake and responsive?
Is he playful, crying and moving well? Or he is lethargic and listless? Difficult to wake?
Is there any sign of dehydration like very dry mouth, sunken soft spot?
Is he sucking well?
Did he pass any stool? What color was stool?
Is he passing urine regularly? How many diapers per day? (< 6/day needs
evaluation)
Has he passed urine in last 8 hours (Not = Dehydrated)
What color is urine?

Does he have any fever or low temperature? Did you measure it?
Does he have Cough, pulling ear, runny nose,
Does he cry while paasing urine?

When did you start breast feeding the child?
is he exclusive breast fed baby or r u giving him bottle too? Is he bottle fed?
Are you adequately breast-feeding him?


What™s your blood group?
Do you know the blood groups of your husband?

PAMHUGSF

Does he have any pain in his belly? (No, he didn™t mention it)
Does he have any problems with his bowel movement? (He has constipation)
Does he have any problems with his urination? (No)
Does he have any problem with sleeping?


PMH
Has he ever been diagnosed with any medical illness before? (No)
Is he allergic to anything? (No)
Is he taking any medications? (No)
Has he ever been hospitalized? (No)™
Any history of bleeding disorder?
Any history of fit?
How is the health of other children?

Development history
Are his immunizations up to date? (Yes)
When did he visit his physician last time?
How is his growth & development on the whole?


Birth history
Was the child conceived naturally or by assisted reprodution?
At what gestation was he delivered?
What was the mode of delivery?vaginal delivery? Do u have any idea about duration of labour?
DO u know the birth weight of your baby?
Did u have any complication before during and after delivery?
Did your child needed any type of resuscitation immediately after birth?
Did he had any problems after birth?
any concerns from screening tests at child health clinics or school?
How many children do u have? How old are they? R there any health problem on other children?
Any miscarriage or abortion?


SH
What do u work as? What does your partner do? Who looks after the child if u work?
DO u have any housing issues or problems? does anyone in family smoke?
Who else live at home? Does he or she looks after him
Any pets at home



FH
Does anybody in family have similar problem?
Does anyone in your family have bleeding disorder, liver disease?


Mrs. Xxxx,First let me summarize what you have just told me. You said ... Is
that right? (Yes)

Would u like to add anything?

Mrs. Xxxx , according to the information I gathered from you, I™m considering a
possibility of physiological jaundice. During their first few days of life, more than half of all full-term babies and as many as four out of five premature infants who are otherwise healthy develop jaundice,
But sometimes a baby may develop jaundice for other reasons. Like Severe bruising during delivery, An infection in your baby's blood (sepsis,) An incompatibility between your blood and your baby's blood group, An enzyme deficiency and an abnormality of your baby's red blood cells
I would advice u to bring the child to the medical center to rule out other causes. Which might need a physical examination and some blood tests.

In the mean time I would recommend you to Keep baby well hydrated. Increase the frequency of feedings. Nurse your baby every 1½ to 2½ hours during the day. Don't let your baby sleep more than 4 hours at night without feeding.
Hope you understood whatever we discussed today?
Do you have any concern or question?
Alright then, I will see you once you get to the hospital. Take care.

If Challenging question ask-
Why does it occur since my baby is healthy? Do I need to worry?
Infant jaundice itself isn't a disease. In most cases infant jaundice occurs because your baby's liver isn't mature enough to metabolize a molecule called bilirubin, which normally forms when the body recycles old or damaged red blood cells.
It doesn't cause discomfort for your baby, and it usually disappears on its own in one to two weeks Still, infant jaundice should be closely monitored by your baby's doctor because severe jaundice can lead to serious complications. Treatments can help keep your baby's blood level of bilirubin from becoming too high.
If your baby is 5 days or older AND has less than 3 stools/day, carefully insert a
lubricated thermometer ½ inch (12 mm) into the anus and gently move it from side
to side a few times to stimulate a stool (Reason: increased stools carry more
bilirubin out of the body. Do this once or twice per day until jaundice improves or
stool frequency becomes normal.

(Jaundice within 24 hrs or Color geting deeper after 7 days old or Jaundice is not
gone after 14 days of age or Jaundice began or reappeared after 7 days of age
require attention)
(First 24 hrs after birth: Pathological? ABO/Rh)

Pick

[ArchivalUser]

BUMP

[ArchivalUser]

five stars

thank you so much