CS Mnemonics and Other imp material

Psychiatry Patient :

Mental status exam: Patient well groomed or not Eye contact, flight of ideas Speech pressured/not Mood/Affect Hostile or not to examiner Co-operative or not Inattentive/atten. 3/3 for registration,3/3 recall,3/3 orientation, long term memory, concentration,judgement,comprehension



Paeds Patient: the primary informant is the mother(1st sentence) Birth Hx,G& D, Immunization HX, SocialHx-smokers at home, sick contacts,day care, siblings going to the day care OB/GYN: Sexual HX:STDs, vaccination against Rubella,Hep B, Smoking(increases risk of CA), Blood transfusions in the past

i divide the exam in 5 catogeries: opening,CC+HOPI,GE+SE,Summary+councelling, Close. once you enter CS center: see the the usmle video..it helps u to the feel of the actual exam which cannot be replaced by anything.. 2) when u r standing at the door and the announcement is made for u...the first thing u write is the patients name...belive me 8 out of 12 times at the end of the case i forgot abt the name...write as big as u can and when u come in room plz keep the pad upside down...so that the SP may not see what u have written...just my personal advice..then u write the

PAMHUGSFOSSOSDA

LIQORAAA

FCCNDTCHMMSR ..( REMEMBER THE DD )

3) the moment u come in after knocking the door..smile...greet the patient..shake hand...i m dr.mmm a physician here to help you....( a advice.... if the SP is not able to talk or in pain...u can directly start with like...mr.SP the nurse told me that you have pain in abd..how may help you with that..or can u tell me more abt it....

U can use the mnemonic - FCC NDTV HSSR for that..

F-FEVER
C-COUGH
C-COLD
N-NAUSAEA,NUMBNESS
D-DIZZINESS
T-TINGLING
V-VOMITTINGS
H-HEADCAHE
S-SORETHROAT
S-SHORTNESS OF BREATH
R-RIGORS,
RASH

4) there are 10 transitions sentences u have to use and 4 informative one...u cannot miss them in any case...make it like a routine when ur practising these cases..

5) u can talk while washing hands....dont have slience any time in the room unless u ascultating...

6) Ok now the big thing..examination...its so time consuming and u tend to forgot all the things.. 7) for general exam..follow the PICKLE and added O of opthalmoscope to it...check pedal edema now...and ask fr it also...check pulses...take BP

8) now for,, systemic exam... --start with sp sitting , untie the gown with
back chest insep/percussion/tactile fremituis/ascultation....check for spinous tenderness and CVA tenderness at the same time.. ---
SP still sitting..come front take the gown down ..sternal tenderness/ supraclavicular nodes axillary nodes...
PMI...all 4 heart sounds and ascultate the lungs.. --
tell the SP to lie down....look for JVP..carotid pulse...
go for abdomen...IAPP..

9)...summary...the most imp part...what u told me..what i found out...it might be (DD)..what we are going to do (investigations).. ---counselling..the most imp part of the closing....u have to do ....what precuations the SP has to take based on the CC..

10) closing....ok this is what i did.. a) i m going to tell the nurse to send the investigatiosns quickly b) the investigations might take 8-12 hours to come..till the time if there is any problems or worsing the CC plz give me a call ..i m goin to keep my contact info with the nurse.. c) and once the investigations comes we will meet again and dicuss abt the problem and management..i would like to again remind you abt i am alwayz here to hep you Mr.SP ..have a great day.!!!! Phew finish..come outside and start writing the PN.. writing PN is easy...so i guess i m not going to write abt it... .



1)Knock 3 times with confidence , a smile , walk in and say, "hello Mr. SP, I am Dr. XYZ and am here to see you today as your physician." Shake hands with the patient, look around the room and say "Is everything in the room alright for you ?" - SP says yes - Then you say "Let me make you a little more comfortable".....and while saying so, drape the patients legs up to his belly (applies to a sitting or a reclining SP) . Then, "So Mr. Smith, how may I help you today?" After the patient tells you the chief complaints and stops, first express sympathy - say, "Oh I am sorry to hear that, I shall try my best to help you. Hope you dont mind if I make a few notes as you speak" This makes you free to write or pretend to write as you try to recall what to ask without showing ur nervousness - actually a good time to write ur mnemonics !! now ask LIQORAAA + FCCNDTVHMSSR --2) hello Mr.SP now i need to ask you more Q regarding ur health..which will help me nderstand ur health better....NOW ASK FOR START WITH off with data collection, i.e. "PAM HUGS", before you move on to "FOSS", it is good to say, "Mr. SP, the way clinical medicine works, there could be some clues hidden in a few personal questions I need to ask you - is that OK with you ? " and then move on to FO ---4) now tell the SP that anything u going to tell is going to be confidential....ask the sexsual and social SODA. --- Transitioning to a hand wash: There have been quite a few concerns about how to handle a change from history mode to a hand wash mode ...A sample transcript : You = "I shall now need to perform a quick general examination and then look at your heart - is that fine ?" (No need to say Head, Neck, Eyes, Feet, etc and waste seconds ! - you're gonna be graded for doing it , not for u saying it in detail !) SP = "Sure, doctor" You = "Arrite ! Before we begin Mr. Smith , excuse me for a moment here to wash my hands" (smile) I had reserved the time to wash my hands to enquire about occupation and say "thats interesting, my uncle used to do something similar" or something like that. Transitioning to a Physical exam: Before you begin physical examination say "I will now need to perform a quick general examination and then we shall have a look at your chest [or abdomen - wutever the chief complaint is]" and do keep talking during each thing your examine - like "lets start with your eyes, could you look up for me" while examining pallor. By the way , a good mnemonic of quickly completing general examination is "PICKLE" - Pallor, icterus, Cyanosis, Clubbing, Koilonychia, Lymphadenopathy and Edema Feet" along with Jugular veins, carotid bruit if a CVS case. At the end of the entire general + systemic examination, summarise : "Based on what you told me and your physical exam, there are certain diagnostic possibilities like 1._____, 2. ________ or 3. _______ and others. But to be more certain, let us order a few tests - like blood tests, chest x-ray , an EKG , and then discuss further management. " The last minutes... While concluding, keep this 4-stage pattern in mind to cover everything and to be courteous: a. First, Counsel !!! For example - for a case of diabetes, it is good to say a few words on foot care ! if the patient smokes or drinks alcohol - say "are you aware of the harmful effects of smoking / alcohol ? Have you ever considered quitting - if you wish to , we have a good support team that is willing to help you quit the habit" thats it - dont get personal about it . b. Then say " Have you understood everything we have discussed today ?" c. Then "Are there any special concerns you have ?" d. Finally " Thankyou very much Mr. SP . I shall leave my contact information with my nurse - feel free to contact me anytime if you have any questions"Last day practice;general case 2) pedis case 3) pyshicatry case 4) absue case 5) telephone case.. take some sweet and start walking to the center ( i ate gulab jamun) yes the center is on the 5th floor....once ur out of lift take left and u r in the exam place.... talk to everyone u meet ...i had a girl from cincinnati next to me..we were talking abt the seinfeild episode in which kramer and his brother are SP's and were laughing abt it...its very relaxing.. but remember one thing dont talk abt the cases to anyone anywhere...period.. plz dont eat onions in the lunch..and bring some those breath dissolving things with u..plz plz bring those.. plz bring hankercheif...u get so sweaty...u need it before u knock on the door.. i just did the kaplan book and u have plenty of time buddy..10th june to 27th july...wow..i wish i could have that time VASES: In domestic abuse. Violence, Afraid, Safe, Emergency plan, Support system DEATH & SHAFT: Activities of daily living. Dressing, Eating, Ambulating, Toiletting, Hygeine. Shopping, Housekeeping, Accounting, Food preparation, Transportation. FROM HIS JFK CASE: Mental state exam (overlaps with SIG E CAPS actually) Funtionality Reasoning Orientation/ Outlook Memory/ Mood Hallucinations/ delusions Insight Speech/ Sleep Judgement Feelings Knowledge Concentration Attention/ appearance Suicidality Energy for depression - FACE SIPS F - feeling - shame guilt, sadness, anger A - appetite C - concentration, memory E - eneregy level S - sleep pattern I - interest in normal activites , hobbies P - pscyhomotor retardation S - sucidial ideation/intentWeight, Appetite, Diet, Stress, Exercise and Travel (WAD SET) only in GI, depression or possible endocrine (Thyroid, Cushings, PCOS) cases.I would the following questions in personal history after appropriate transition sentence- "Are you sexually active". If yes, I would ask "How many sexual partners have you had in the past six months". This I used instead of asking "Do you have multiple sexual partners" which I was not comfortable asking. Also, I found the question "are your sexual partners male or female or both" a little offensive though we may be required to elicit such information. So, I decided to reserve that question only in someone for whom I had high suspicion of STD along with "Have you ever been tested for STD". If the SP gives history of multiple sexual partners, then I would ask "Do you use condoms". If yes, I decided to leave it at that, especially if the history was that of a stable relationship. If I had to counsel specifically for STD, "There is a risk of infection with sexually transmitted diseases in anyone that is sexually active. The risk is increased when there are multiple sexual partners. Abstinence from sex is the best method to prevent infection with and spreading of sexually transmitted diseases. When this is not possible, the risk is reduced by limiting the number of sexual partners and using condoms which are also a reliable method of contraception." For psych cases, the counselling would ofcourse depend on the diagnosis which will be quite different for Alzheimers, depression, schizophrenia etc. Hope that helped. All the best for your exam.For PR u can tell - 'we will be examining ur back passage with one finger, its not painful but may cause bit discomfort'.When i explained about pr the SP asked the q ,whether it hurts doctor?. Counselling of lab result - My opinion is u should tell all the cases what investigation u are going to do in layman's term. There will be atleast one ER setting, just let the patient know that u care for their pain and will sort the pain as soon as the PE is over. The center will open at 7.30, they will def start the orientation at 8.00 am.Exam will be over by 3.30.U will get a 30 mt break after 5 cases, then 15 mt break after 4 and then 3 cases [ 12 cases ] .I hope that covers everything.I will be ready to help , in case u have anymore doudt.Mnemonics for psychiatrics SP. 3 mnemonics goes for it. 1. O.P.C. Onset: when did your fatigue start? there can b 2 kinds of answers to this Qs. group A: "2 months ago" for SP with PTSD, adjustment dis, malingering, cancer or other illness, etc. group B: I've been tired all my life or it comes and goes for SP with major depressive dis, cyclotimia, etc. Previous: have you ever had it b4? this Qs applies only to group A bcos group B already answers to it. Most of the answer group A will give will b a NO Cause: it is now the case, to ask to both groups a nice open ended Qs: what do you think is the cause of your problem? group A would give the important clue. MVA in case of PTSD, separation in case of adjustment dis, abdominal pain in case of possible pancreatic cancer. etc. if group A does not give the answer SPECIFICALLY ASK what happened 2 months ago? most of group B SP will say I don't know doc. cos they have felt like this all life. (but even group A SP could answer that)). NOW WE GO TO THE 2 MNEMONICS 2. FACE SLIPS 3. then I finish with PAM HUGS FOSSODA If SP has any other complaint, like pain, I have to investigate it through LIQORAAA and introduce it in my D/Ds and work up. I tried this system with all the psychiatrics chief complaints and it works.In case of fatigue, I have to ask: do you feel it all day long or you feel better in some particular moments? if yes, I investigate which moments. I put this Qs at O (onset), after asking when the fatigue started. In case of depression or feeling low, I have to ask if he generally looks at things in a positive or a negative frame of mind. I put this Qs in F (feelings), after asking If he has feelings of worthlessness. In case of PTSD, I have to ask about nightmare related to traumatic event. Even in this case I put the Qs in feelings, after asking about feelings of guiltinessI must always consider hypothyroidism as a D/Ds. also, I must always ask about delusion and hallucinations. But where to insert these Qs? maybe I should modify the Mnemonic from FACE SLIPS to FACE SLIPSO, with O being Others (actually 2 Qs: do you feel cold when other don't? do you hear or see what other people don't?) For the chief complaints which are neither Psychiatrics nor pain, I will use the following 2 Mnemonics. OAAA, where O is the onset the same from psychiatric history and AAA is (associated, aggravating and alleviating factors) taken for pain history. then I will continue with PAM HUGS FOSSODA. As a general rule, I will use this for all symptoms which are not psy (fatigue, depression, feeling low) or pain related (cefalea, sore throat, knee pain, etc. where LIQORAAA will be fine) The problem of these mnemonics is that if I want to make the history as much complete as possible, I often need to apply more than one Qs to some letters. Let's consider a chief complaint of knee pain for exemple. To perform a proper interview I have to apply more than one Qs to the letter O. Location: Could u plz tell me exactl where you feel the pain? Intensity: on a scale... howould u rate? Quality: how would u describe the pain? (important open ended Qs) Onset: here, I have verified that asking only when the pain starts makes the interview incomplete. So the Qs will b: 1. when did it first start? point X 2. have you ever had it before? before X 3. do have everyday? and all day long? if it is not all day long ask how long it lasts. after X 4. Is it worsening days after day or it is the same? progression Applying this Qs to Onset makes the History more complete. Radiation: does the pain move? Associated Symptoms: Do you have other problem other than this, for exemple fever, nausea, vomiting, diarrhea (it is important to give exemples and went the SP is done I ask anything else?) Aggravating factors: Do you know something that makes is worsen? Alleviating factors: ... that makes you feel better? Let's then return to the top. For all complaints that will not be psy or pain, I will use OAAA and then PAM HUGS FOSSODA. But in this case, I would apply to O the same 4 questions as above.According to many sources I have to make a transition sentence before starting with LIQUORAA or OAAA, and then between PAM and HUGS, between HUGS and F, between F and O, between O and S, etc, etc. For one who have been practising medecine like me this sounds really weird. Even my personal SP (which happens to be from the US) told me that all that transition sentences make the interview weird. keeping saying always "Now I need to ask some Qs about past medical history, is it ok? now I need to ask you about your family is it fine? I need to know more about your personal life is it okay with you? now I need to know about you social life is it fine? now I need to examine your chest? now it is the turn of your head, I need to palpate your belly. I need to check your pulse is it fine? is it fine? is it fine? is it fine? is it okay? is it ok? ok?ok?ok?ok?ok?ok?ok? COMEON!!!!!!!!!!! Maybe I do not do my transitions properly. But according to usmleworld I have to do these transitions. Now here is the deal: I know they want me to show professionality, compassion and respect. I do have a great deal of it. But I know I will not feel comfortable during the exam if I say it as it is described in usmleworld. So the deal is ask permission and describe what you are going to do in the same sentence. before going through the LIQORAAA I will say: I have been informed that you came in today because of abdominal pain. Could you pls tell me more about it? (I will not say what brings you in today? because I have read of one who recieved in response by the bus. In the same way, I will not ask why are you here today? because we are in a hospital and when we visit a patient we are supposed to know the chief complaint. In order to avoid any pb at the beginning of the interview, I think it would be better to start with a "closed ended Qs" I know that you are here because of abdominal pain, could you please tell me more about it? I think this gives an idea of professionality because it means that you get informations about the patient before seeing him. After the patient answer, I will say: I'm sorry to here that (only if it is the case). I need to ask you some questions about your problem, just to have a good view of it. Is it ok with you miss jones? yes. thank you very much. Then I will procede with the LIQORAAA then before going to PAM HUGS FOSSODA I'll say Now miss Jones, I will ask you some few Qs about your personal health, your personal life and your family. ok? okay! pls don't be embarrassed by my Qs because everything we'll talk about in this conversation will remain absolutely confidential. Then I'll go on. Let's then summarize the history taking. 1. In case of pain: LIQORAAA where O is related to 4 Qs and then PAM HUGS FOSSODA 2. In case of psy complaint OC (P is inside O) FACE SLIPSO PAM HUGS FOSSODA 3. In case of a complaint that is neither psy nor painful OAAA Cs advice ;;;Mr.Jones,....i want to tell u abt a few lifestyle changesU need to make at this point..----Monitor ur bp/sugarregularly, & don't miss u'r drug doses, eat healthy(low carb/low fat diet/low salt diet) & take extracare of ur feet, wear soft footwear & make sure u dontget hurt.As far as smoking and alcohol r concerned, uneed to seriously think abt quitting, it's never too lateto quit, espy if u r a dm'tic/htn'sive.. u need to be aware of their direct illeffects on the heart, brain & lungs..onlong term basis...I know it can be very tough to quit, buti cud introduce u to our peer support groups here, for goodphysical and emotional encouragement....let me know if u rinterested...& feel free to ask me any of ur concerns, my contact numbers r with my nurse...Is there anything u wantto ask me....Shall i see u then...good seeing u mr.jones.....



For the Phone Encounter-

"ON CALL IDIOT"

['On Call'since this is a phone encounter] - please dont think about "idiot" being offnesive - it is just a mnemonic people !O - Onset ?N - Number of Times a Day?C - Consistency ? / Color? / Content ? [Blood, Fat, Mucous ?] + Crying ? Cramps Suggestive ?A - Associated Symptoms [Fever, Runny Nose, Rash, Cough, Ear Discharge, Vomitting, Rash ?]L - Listless baby ? Lethargic, not Sleeping ?L - Liquids not passing ? [i.e. not urinating ?]I - Immunization up to date ?D - Diet Change ? Dehydration signs ? Day Care Center ? Developmental MilestonesI - Infections in family ? Immunicompromised mom ? [HIV ?]O - ORS counseling (Oral Rehydration Solution - see below)T - Travel history recently ?