SPECIFIC COMPLAINTS

Shortness of breath
DOPCSFLIQRAAA + 4 associated symptoms -cough -palpitations -chest pain -loss of consciousness 5 specific questions -PND (intensity) -orthhopnea -wheezing -' (intensity) -fluid retention DOPCSFLIQRAAA +

Do you wake up at night short of breath? Do you have problems lying down? Have you been wheezing? How man steps can you climb before you get short of breath? How far can you walk on level ground before you have shortness of breath? Have you noticed any fluid retention around your ankles? Do you have a cough? Do you have chest pain ? any chest pain? Do you have palpitation? Any heart racings? Have you ever lost of consiousness? Asso.symptoms

Examination

Performed eye examination with ophthalmoscope Looked for JVD Palpated for PMI Listened my heart Auscultated all over the lungs Percussed for liver span Checked for pedal edema Checked peripheral pulses

Forgetfulness and confusion

things -please tell me the things that you usually forget? Or what kind of things do you usually forget? Concentration -Any difficulty concentrating? Or is it difficult for you to concentrate? transferring from your bed to the chair going to the toilet Bathing Getting dressed Feeding

Daily activities

-Can you still perform your daily activities? -Do you need any help transferring from your bed to the chair, bathing, getting dressed, feeding?

Lost interest in social activities(shoppings + hobbies) -Have you lost any interest in your social activities? -Do you have any problems with shopping/ cooking/ housework/ paying the bills? -What hobbies do you have? Do you enjoy them? Hurting yourself -Have you ever thought about hurting yourself or ending your life?

 causes
Head -HA -light headedness(LH) -loss of consciousness (LOS) -speech problems Ext. -sz. -weakness/numbness (wk/nm) -fall (F) -walking pbl. (gait) Eyes -changes in vision(VC) Heart -heart pbl. -high blood pressure -chest pain(CP) Lungs -shortness of breath ( SOB) Abd. -abd. Pain -loss of bladder control -N/V Head -Have you ever had headaches -Any lightheadedness? -Have you ever passed out? -Any difficulty speaking? (speech problems) Ext. -Do you any walking problems? -Have you ever fallen? Any head trauma in the past? Did you see the doctor for that? -Have you ever experienced seizures or shaking? -Do you have any weakness or numbness? Eyes -Any changes in your vision? Heart -Do you have any heart problems? -Any chest pain? -Have you ever experienced high blood pressure? Lungs -Any shortness of breath Abd. -Any abdominal pain -Any nausea or vomiting? -Have you lost control of your bladder? +/-Do you have any family members or friends that you can talk to? - Any traumatic events in your family?

PE EYEs-pupils, fundoscopic exam. Neck-carotid bruits Heart-auscultation, orthostatic V/S Lungs-auscultation Abd.-palpat. Neuro.-minimental status, CN, motor, DTR, gait, Romberg, sens.

Knee pain
-Do you have pain in other joints? D O P C S-Did you injure(# your knee? ) F L I-Do you have problems walking? Q R A A A-associated symptoms Joints -swelling(SW)-Have you noticed any redness or swelling of the joint? -redness(R) -warmth(W) -morning stiffness(MS)-Do you have morning stiffness in your joint? HEENT -Hair loss (HL)-Do you lose your hair? Or Have you noticed any hair loss? -oral ulcer-Do you have oral ulcers? -fever-Do you have a fever? -fatigued-Do you feel fatigued? Heart -chest pain(cp)-Do you have a chest pain? Lungs -SOB-Do you have shortness of breath? Abd. -pain-Any abdominal pain? Ext. -rash + photosens.-Any rashes with your joint pain? Is it affected by sun light? -numbness-Do you have numbness? -weakness-Do you have weakness? -Raynaud phenomenon-Do you have any pain in the tips of your fingers when it is cold? -Have you ever been bitten by a tick? - + mens, pregnancy, abortion, std PE HEENT- H&LAbd.Ext.- ROM

joint # skin

Tremor

DOPCSFAAA (-F) -Please show me exactly where is the problem? -When did you first notice? -Please tell me about your tremor? -Does it come on at any particular time? -Does anything make it better? -Does anything make it worse? Associated symptoms Head -headache-Do you have headaches? -head trauma Hx-Have you ever had head trauma? -depressed-Do you feel depressed? -voice changes-Have you noticed any changes in your voice? Ext. -hand-writing-Have you noticed any changes in your hand writing? -fallen-Have you ever fallen? Or any trouble with your balance? -Do you have any difficulty with your daily activities? or Does it affect your dily activities? -Have you ever had the same problem before? -Do you drink caffeine?

Loss of Consciousness (pass out)

DOPCSFAAA(-PCFAA) DDx -TIA -Seizure -SVNCOPE -Please tell me what happened? D-When did it happen? S-What were you doing when it happened? A-Did you lose your consciousness before, during or after you fall? -Did you hit your head? -How long did you lose your consciousness? Preictal - aura Seizure ictal shaking, tongue biting, lost control of your bladder Postictal-confused -Did you sense something unusual before losing consciousness?(I mean hear/smell/see something) Vasovagal sync.-Did you have palpitations/ lightheadedness before you fainted? -Did you feel nauseated before you fainted? Did you feel sweaty? -Did you shake while you lost your consciousness? -Did you bite your tongue? -Did you lose control of your bladder during the event? -Did you feel confused after the event? How long? Or Did you have any symptoms after regaining consciousness? TIA -Did you have any weakness or numbness? -Do you have speech or gait difficulties? Or Any trouble with your balance? -Any headaches? -Have you ever had head trauma? SVNCOP S-what were you doing when it happened? V-nausea, sweating, palpitation, lightheadedness. N TIA C-Do you have chest pain? Do you have abdominal pain? -Any shortness of breath? O-what were you doing when it happened? P-

Weight gain

DDx -smoking cessation -drug SE -Hypothyroidism -Cushing syndrome -PCOD -DM -Atypical depression -pregnency

smoke

DOPCSFAAA -How many pounds do you gain? For what period of time? Hypothyroidism Cold intolerance-Do you have cold intolerance? Hair/skin-Have you noticed any changes in your skin or hair? Constipation-Are you constipated? Fatigue-Do you feel fatigued? Pregnancy LMP-When was the first day of your last menstrual period? -Have you noticed any changes in your periods? -Have you ever been pregnant? -Were there any problems with your pregnancy? -Have you ever had a miscarriage? -Any abortions? DM Urinary pbl.-Any urinary problems? Do you have to urinate more often than usual? PCOD Voice changes-Have you noticed any changes in your voice? Hirsutism-Have you noticed any abnormal hair growth recently? Atypical depression depression-Do you feel depressed? Sleep pattern-Do you have problem falling asleep? -Do you have problem staying asleep? -Do you have any problem waking up? ROS -Do you have a fever? -Do you have chest pain? -Do you have shortness of breath? -Do you have abdominal pain? PE - -LN, thyroid -DTR -pulses

Missed periods

DDx -pregnancy -menopause -premature ovarion failure -Anxiety induced amenorrhea -PCOD -Sheehans syndrome -pituitary tumor -Ashermans syndrome -prolactinoma -thyroid disease -anorexia nervosa DOPCSFAAA Pregnancy LMP-When was the first day of your 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? Menarche- At what age did you have your first menstrual period? Thyroid disease Cold intolerance-Do you have cold intolerance? Hair/ skin changes-Have you noticed any changes in your hair or skin? Fatigued-Do you feel fatigued? PCOD Voice changes-Have you noticed any changes in your voice? Anorexia nervosa Diet-Tell me about your diet. Any changes in your appetite? -Do you have any special diet that you follow? Depression Depressed-Do you feel depressed? Stressful events-Any stressful event in your life? Menopause -Do you have vaginal dryness? -Do you have hot flushes? Pituitary tumor Vision-Any changes in your vision? HA-Do you have headaches? Nipple D/C-Do you have any discharge from nipples? Sheehans syndrome -Have you ever been pregnant? -Were there any problems with your pregnancy or your delivery? -Have you ever had a miscarriage? -Any abortions? -Have you ever had a PAP smear before? What was the result? P.E. -visual fields -EOM -thyroid -DTR

Pain during sex DOPCSFLIQRAAA

DDx AVCDEF -Atrophic vaginitis -Endrometriosis -cervicitis -depression -domestic abuse(Family) -vaginismus D-How long have you had this problem? -Please describe the pain. F-How often do you gget this pain. L-Can you tell me exactly where you feel the pain? Cervicitis Vg.D/C-Do you have vaginal discharge? itchiness-Is it itchy? Or Do you have itchiness? douch-Do you douch yourself? Bleeding after sex-Have you ever had any bleeding after sexual intercourse? Domestic abuse Conflict-Do you have any conflicts with your partner? Safe at home-Do you feel safe at home? Abuse- Have you ever been abused? Vaginismus Sexual desire-How is your sexual desire? Depression depression-Do you feel depressed? Sleep pattern-Do you have problem falling asleep? -Do you have problem staying asleep? -Do you have any problem waking up? Atrophic vaginitis -Do you have vaginal dryness? -Do you have hot flushes? Endometriosis Pregnancy- Have you ever been pregnant? Spottings-Have you noticed any spotting between periods? Pain during bowel movement-Have you ever had any pain when you have a bowel movement? # # -LMP,I,D,Menarche,amount, dysmenorrheal,abortion,PAP P.E. , +PV

Back pain
DDx -Lumbar muscle strain

-disc herniation -tumor in the vertebral canal -lumbar spinal stenosis -Vertebral compression fracture -TB spine -metastatic cancer -Ankylosing spondylitis DOPCSFLIQRAAA R-Did the pain travel anywhere else? How far down? -Is there any associated events related to your symptom? -Did you lift heavy objects? Lumbar muscle strain A-Do you only get the pain if you change position? -In what position is the pain worse? Tumor -Does the pain come on at any particular time of the day? -Is the pain worse at night? Ankylosing spondylitis -Do you have stiffness in your back first thing in the morning? Or do you have morning stiffness? TB spine -Do you have a fever? -Do you have night sweats? Complications -Do you have any weakness/ numbness? -Do you have any difficulties urinating? Or Do you have any problems passing water? -Do you lose control of your bladder? P.E. - ROM Ext. - pulses, hip Neuro. - # -SLRT -gait(including heel and toe walking)