Depression • Weight loss

• Loss of appetite
1. WIPPPE (Wash, Introduce, Permission, Privacy, Explain) • headache
2. Patient information: Name and Age • Infection: runny nose, sneezing, sore throat, cough, skin lesion, STD
3. Chief complaint: What brought you here today?
4. Female: married, children, menstrual cycle, pregnant Exacerbating & Relieving Factors
5. SOCRATES: • Exacerbating: Job or school, social life, stress
• Relieved: Sleep or rest, self harm or destructive behaviour
Onset: Severity: Affects daily life
• When did it start (Acute/chronic)
• Continuous / on and off
- If intermittent how long does one episode last 6. PDFS
• Progression (getting worse, better)
• Preceding events: Trauma, loss of job, family or friend, pregnant or gave birth recently Past medical and surgical history:
• Similar presentation
Associated Symptoms: • Previous investigation (ask about imaging, blood transfusion, etc)
• Previous Hospitalization (ask about radiation, and chemotherapy)
DIGS SPACE • Hospitalized due to drugs, psychiatry or suicide attempt
• Previous Surgery or intervention
• Depressed/low mood • Chronic diseases: diabetes, hypertension, dyslipidemia, Cancer, infections
• Loss of Interest • Diseases of the system:
• Guilty or worthlessness - Psych: Depression, anxiety, PTSD, schizophrenia, etc
• Sleep disturbance (increase or decrease) - Sleep: insomnia, OSA, Sleepwalking, snoring
• Suicidal ideation (thought of hurting yourself, thought of taking your life, plan, attempt) - Neurological: Epilepsy, restless leg syndrome,
- Endocrine: Hypo/hyperthyroidism , anemia
• Psychomotor agitation (restless, irritable, anxious) - Menstrual cycle (female)
• Appetite (increase or decreased)
• Poor Concentration Drug History
• Low Energy • Allergy
• Vaccination (hepatitis)
Psychosis: • Are you currently taking any medications: analgesia, antibiotics, antidepressants, beta-blockers,
benzodiazepine steroids, OCP, Herbal preparation
• Hallucinations (hear voices speaking to you when you’re alone) • Side effects from the medication you currently take? + Specify Type & Dosage & Duration
• Delusions (someone putting thoughts in your head)
• Paranoia (Someone is out to get you) Family History:
• Similar presentation
Bipolar (Mania) • Chronic diseases: diabetes, hypertension, dyslipidemia, Cancer
- Hx of suicide
• Times when you feel high/energetic/euphoric excitement or elevated mood while rapidly - Psych: Depression, anxiety, PTSD, schizophrenia, etc
talking and no one can understand what you were saying? Spending large amounts of
money?
- Endocrine: Hypo/hyperthyroidism

Anxiety: Social History:

• Social support (husband, friends, family)
• Have you felt anxious & your heart racing
• Pregnant or gave birth recently
• Wanting to avoid social situations • Stress (financial, occupational, relationships)
• Sexual activity (loss of interest or high risk)
Medical conditions: • Lifestyle and exercise
• Hypothyroidism: “Have you experienced weight gain with dry skin? Have you noticed • Caffeine and Diet
• Smoking
a preference for cold or hot temperatures recently (Cold intolerance)?
• Alcohol
• Anemia: “Have you experienced fatigue, palpitations, Dyspnea, jaundice, and hair • Drug use
loss?” • Travel

Systemic/ Red flag: 7. ICE

• Night sweats 8. Wash hands and thank you
 Heachache • Diseases of the system:
- Neuro: migraine, stroke, multiple sclerosis, epilepsy, brain tumor
1. WIPPPE (Wash, Introduce, Permission, Privacy, Explain)
Drug History
2. Patient information: Name and Age • Allergy
3. Chief complaint: What brought you here today? • Vaccination (hepatitis)
4. SOCRATES • Are you currently taking any medications: analgesia, antibiotics, steroids, aspirin, anti-platelet or
- Site anticoagulant, OCP
- Bilateral, unilateral, frontal, temporal, occipital, eyes, ears, para nasal • Side effects from the medication you currently take? + Specify Type & Dosage & Duration
- Localized then diffuse
Family History:
- Onset • Similar presentation
- When • Chronic diseases: diabetes, hypertension, dyslipidemia, Cancer, infections (meningitis,
- Sudden or gradual encephalitis)
- Continuous or on/off • Diseases of the system:
- If intermittent: How long does each episode last - Neuro: migraine, stroke, multiple sclerosis, epilepsy, brain tumor
- Progressively worse •
- Preceding events: trauma, syncope, seizure or tremors, aura
Social History:
- Character: Describe the pain. Dull, throbbing, worst headache of your life • Married, children
• Occupation: chemical, radiation, or UV exposure
- Radiation: neck, radiate to all head. • Diet
• Stress and lifestyle
- Associated: • Pets
1. Migraine: Nausea, vomiting, phonophobia, photophobia, Visual disturbance • Smoking
2. Cluster: Nasal congestion, discharge, eye redness • Alcohol
3. Sinusitis: facial pain, anosmia, post-nasal drip • High-risk activities: Drug use and sexual
4. Meningitis: fever, neck stiffness, rash • Travel
5. Increases ICP: nausea, decreased or loss of LOC, weakness, seizure
6. Temporal arteritis: Dizziness, blurred vision, jaw claudication 7. ICE
7. Red Flags: 8. Wash hands and thank you
- Fever, weight loss, loss of appetite, night sweat
- Change in mental status
- Time: morning, night, end of work, etc.
- Exacerbating :
- Light, noise
- Stress
- Sleep deprivation
- Exercise, movement, position
- Bending forward, Sneezing, coughing (high ICP)
- Food (caffeine, chocolate, cheese)
- Touching the scalp
- Relieving:
- Medication
- Rest, dark
- Laying down

5. PDFS
Past medical and surgical history:
• Similar presentation
• Previous investigation (ask about imaging, blood transfusion, lumbar puncture etc)
• Previous Hospitalization (ask about radiation, and chemotherapy)
• Previous Surgery or intervention
• Chronic diseases: trauma, diabetes, hypertension, dyslipidemia, Cancer, infections (meningitis,
encephalitis)
 Weakness •
• Diseases of the systems:
- Vascular: Stroke, Heart Attack, arrhythmia, Peripheral vascular disease, pulmonary
1. WIPPPE (Wash, Introduce, Permission, Privacy, Explain) embolism.
2. Patient information: Name and Age - Neuro Disorders: Multiple Sclerosis, Myasthenia Gravis, ALS, Muscular dystrophy, disc
3. Chief complaint: What brought you here today? herniation, cauda equina, GBS
4. SOCRATES - Infection: Meningitis, encephalitis

Site: Drug History

• Where • Allergy
• Unilateral or bilateral • Vaccination (hepatitis)
• Localized: Distal, proximal, one limb • Are you currently taking any medications:
- analgesia, steroids, antihypertensive (ACEI or CCB: amlodipine), anticoagulant, anti-
platelet, chemotherapy, OCP
Onset: - Side effects from the medication you currently take? + Specify Type & Dosage & Duration
• When (first time seen normal)
• First time
• Sudden or gradual Family History:
• Continuous / on and off • Similar presentation
• Preceding events: trauma, seizure or tremors • Chronic diseases: diabetes, hypertension, dyslipidemia, cancer
• Premature sudden death (what age)
Character: • Diseases of the systems:
• Complete paralysis (cannot use the limb) - Vascular: Stroke, Heart Attack, arrhythmia, Peripheral vascular disease, pulmonary
• slight weakness and decreased range of motion embolism.
- Neuro Disorders: Multiple Sclerosis, Myasthenia Gravis, ALS, Muscular dystrophy, disc
Radiation: herniation, cauda equina, GBS
• Ascending/ descending - Infection: Meningitis, encephalitis

Associated Symptoms: Social History:

Special Senses gave me a MAD FLU • Married, children
• Occupation and chemical exposure
• Stress
Special Senses: loss of vision, hearing, smell, taste, touch (loss of sensation or numbness) Diet and lifestyle
•
Mental Status & Memory (Cognitive dysfunction) • Smoking
Atrophy & weakness in limbs • Alcohol
Dizziness & Dysphagia • Drug use
Fasciculation (muscle twitching) • Travel
Language: Slurred Speech
Urinary incontinence 6. ICE
7. Wash hands and thank you
Red flags:
• Night sweats
• Weight loss Done by: Tala Aletani, Arwa Alghamdi, Manar Betar, Elana Hakeem
• Loss of appetite

Exacerbating & Relieving Factors

• Stress or Activities (fatigable weakness)

Severity: Affects daily life (dressing, eating, driving)

5. PDFS

Past medical and surgical history:

• Similar presentation
• Previous investigation (ask about imaging, blood transfusion, etc)
• Previous Hospitalization (ask about radiation, and chemotherapy)
• Previous Surgery or intervention
• Chronic diseases: diabetes, hypertension, dyslipidemia, cancer, Infection: recent URTI
 Nasal Congestion
Severity: Affects daily life
1. WIPPPE (Wash, Introduce, Permission, Privacy, Explain)
2. Patient information: Name and Age 5. PDFS
3. Chief complaint: What brought you here today?
4. SOCRATES Past medical and surgical history:
• Similar presentation
Site: • Previous investigation (ask about imaging, blood transfusion, etc)
• Unilateral or bilateral • Previous Hospitalization (ask about radiation, and chemotherapy)
• Which nostril and does it alternate • Previous Surgery (rhinoplasty, septoplasty, adenoidectomy) or intervention and post-op
complication
Onset: • Chronic diseases: diabetes, hypertension, cardiovascular disease, cancer, infections current
• When and recurrent (URTI)
• First time • Diseases of the systems:
• Sudden or gradual - Nose: Deviated or perforated septum, adenoids, polyps, sinusitis
• Continuous / on and off - Atopy: Eczema, asthma, allergic rhinitis, food allergy
• Preceding events: - Autoimmune: cystic fibrosis, sarcoidosis
• Trauma or chemical or fumes exposure
• URTI Drug History
• Foreign body • Allergy
• Vaccination (hepatitis)
Character • Are you currently taking any medications:
FACC: Any discharge? - Oral: analgesics, steroid, antihistamine, OCP
• Frequency - Topical: intranasal sprays like otrivin, decongestants, steroids
• Amount • Side effects from the medication you currently take? + Specify Type & Dosage & Duration
• Color (clear, yellow, blood)
• Content (liquid or solid pieces) Family History:
• Similar presentation
Associated Symptoms: • Chronic diseases: diabetes, hypertension, cardiovascular disease, cancer (nasopharyngeal),
EENT + Face infections (URTI), and sick contact
Eye: • Diseases of the systems:
• Pain, discomfort, redness, blurry vision - Nose: septal deviation, sinusitis
- Atopy: Eczema, asthma, allergic rhinitis, food allergy
Ear:
• Pain, Discharge, and Bleeding
- Autoimmune: cystic fibrosis, sarcoidosis
Nose:
• Foul smell, loss of smell, snoring Social History:
• Married, children,
Throat: • Occupation: chemical, radiation, or UV exposure
• Dysphagia, sourness • Diet
Face: • Stress and lifestyle
• Facial pressure/ fulness, or headache • Pets
• Smoking
Red flags: • Alcohol
• Night sweats • High-risk activities: Drug use (cocaine) and sexual
• Weight loss • Travel
• Loss of appetite
• Heachache 6. ICE
7. Wash hands and thank you
Exacerbating & Relieving Factors
• Exacerbating: Done by: Tala Aletani, Arwa Alghamdi, Manar Betar, Elana Hakeem
• Weather: hot/cold and dry/humid
• Position: laying down
• Irritants: Dust, chemicals, pets
• Relieving:
• Nasal spray or nasal wash
• Antihistamine
 Epistaxis 5. PDFS

1. WIPPPE (Wash, Introduce, Permission, Privacy, Explain) Past medical and surgical history:
2. Patient information: Name and Age • Similar presentation
3. Chief complaint: What brought you here today? • Previous investigation (ask about imaging, blood transfusion, etc)
• Previous Hospitalization (ask about radiation, and chemotherapy)
4. SOCRATES
• Previous Surgery (rhinoplasty, septoplasty, adenoidectomy) or intervention and post-op
complication
Site: • Chronic diseases: diabetes, hypertension, cardiovascular disease, cancer, infections current
• Unilateral or bilateral and recurrent (URTI)
• Which nostril and does it alternate • Diseases of the systems:
• Anterior vs posterior epistaxis - Nose: Deviated or perforated septum, adenoids, polyps, sinusitis, allergic rhinitis
• Anterior: blood drips anteriorly through the nostrils - Hematology: clotting disorder, bleeding disorder, or leukemia, vasculitis
• Posterior: blood drips backward to the throat - Autoimmune: RA, SLE, sarcoidosis
Onset:
• When Drug History
• First time • Allergy
• Sudden or gradual • Vaccination (hepatitis)
• Continuous / on and off • Are you currently taking any medications:
• Preceding events: STUFS - Oral: analgesics, steroid, antihistamine, OCP, Anti-platelets or anti-coagulants (Aspirin or
• Stress (emotional or physical like exercise) Warfarin)
Trauma or chemical (nasal/facial fractures or nose picking)
- Topical: intranasal sprays like otrivin, decongestants, steroids
• Side effects from the medication you currently take? + Specify Type & Dosage & Duration
• URTI (rhinitis, sinusitis)
Foreign body
Family History:
Sun (hot weather, under the sun)
• Similar presentation
• Chronic diseases: diabetes, hypertension, cardiovascular disease, cancer (nasopharyngeal),
Character
infections (URTI), and sick contact
FACC: • Diseases of the systems:
• Frequency - Nose: septal deviation, sinusitis
• Amount - Hematology: clotting disorder, bleeding disorder, or leukemia
• Color (dark or bright red) - Autoimmune: RA, SLE, sarcoidosis
• Content (clots)

Associated Symptoms:
Nose: Social History:
• Pain, Congestion, Foul smell, loss of smell, snoring • Married, children,
• Occupation: chemical, radiation, or UV exposure
Bleeding: • Diet
• Is there bleeding from any other orifice? (Hemoptysis, hematemesis, blood in stool) • Stress and lifestyle
• Do you bruise easily? • Pets
• Smoking
Hypovolemia: • Alcohol
• Diziness or syncope, • High-risk activities: Drug use (cocaine) and sexual
• Tachycardia • Travel
• SOB or chest discomfort
6. ICE
Exacerbating & Relieving Factors 7. Wash hands and thank you
• Exacerbating:
• Weather: hot/cold and dry/humid Done by: Tala Aletani, Arwa Alghamdi, Manar Betar, Elana Hakeem
• Position: laying down
• Irritants: Dust, chemicals, pets

Severity: Affects daily life and sleep

 Insomnia Cranial:
• Headaches
1. WIPPPE (Wash, Introduce, Permission, Privacy, Explain) • Memory problems
2. Patient information: Name and Age
3. Chief complaint: What brought you here today? Muscular:
• Muscle tension and tremor
4. SOCRATES
Systemic/ Red flag:
Onset:
• When did it start • Night sweats
• Continuous / on and off • Weight loss
• Progression • Loss of appetite
• Infection
Character
Before sleeping Exacerbating & Relieving Factors
• Sleep Quality • Stress, loss of a job or family member, trauma
- At what time do you go to bed? (Weekday vs weekend) • Caffeine (How many cups per day of soft drinks)
- How long does it take you to fall asleep • Relieved by: Herbal supplements or tea, meditation, medication
- if you wake up in the middle of the night, How long does it take you to fall back asleep?
- On average, how many hours do you sleep?
Severity: Affects daily life
• Sleep hygiene:
- Sleep environment: Noise, interruptions, temperature, light and cell phone, a partner in 5. PDFS
the room,
- Food: A heavy meal or caffeine
Past medical and surgical history:
- Exercise: Do you exercise late in the evening? • Similar presentation
• Previous investigation (ask about imaging, blood transfusion, etc)
While sleeping • Previous Hospitalization (ask about radiation, and chemotherapy)
- Is it continuous or interrupted • Previous Surgery or intervention
- If interrupted: frequency and trigger ( toilet, Nightmares, pain) • Chronic diseases: diabetes, hypertension, dyslipidemia, Cancer,
- OSA: Snoring loudly, gasp, choke or stop breathing during sleep? • Diseases of the system:
- Leg movement: Are uncomfortable feelings in the legs, relieved by moving the legs? Did - Sleep: OSA, Narcolepsy
someone notice limb jerks during sleep? - Psych: Depression, anxiety, PTSD, schizophrenia, etc
- Sleepwalking - Neurological: Epilepsy, restless leg syndrome,
- Endocrine: Hypo/hyperthyroidism
After sleeping
- When do you wake up? By yourself or alarm Drug History
- After sleeping do you feel fresh or exhausted, headache or dry mouth • Allergy
- Difficulty staying awake during routine tasks, Ex: while driving • Vaccination (hepatitis)
- Falling asleep in quiet places • Are you currently taking any medications: analgesia, antibiotics, antihistamines, stimulating
- Do you take naps? antidepressants, benzodiazepine, beta-blockers, OCP, Herbal preparation
• Side effects from the medication you currently take? + Specify Type & Dosage & Duration
Associated Symptoms:
Family History:
• Similar presentation
Psych: • Chronic diseases: diabetes, hypertension, dyslipidemia, Cancer
• Depression: - Sleep: OSA, Sleepwalking, snoring, Narcolepsy
- Loss of interest - Psych: Depression, anxiety, PTSD, schizophrenia, etc
- Low mood - Neurological: Epilepsy, restless leg syndrome,
- If yes ask DIGS SPACE - Endocrine: Hypo/hyperthyroidism
• Mania: Have you experienced periods where you feel euphoric/energetic?
• Anxiety: increased worrying and anxiousness Social History:
• PTSD: a previous traumatic event Married, children
•
• Psychosis: • Occupation: shift worker
• Hallucinations: “Have you ever heard voices speaking when there’s no one around?” • Stress
• Delusions: “Have you ever felt that someone can put thoughts into your head?” • Diet and lifestyle
• Paranoia: “Do you fear people are out to get you?” • Smoking
 • Alcohol Skin lesion- Acne and Atopic Dernatitis
• Drug use
• Travel 1. WIPPPE (Wash, Introduce, Permission, Privacy, Explain)
2. Patient information: Name and Age
6. ICE
3. Chief complaint: What brought you here today?
7. Wash hands and thank you 4. SOCRATES
Done by: Tala Aletani, Arwa Alghamdi, Manar Betar, Elana Hakeem
Site:
• Where
• Face distribution of acne: T zone, cheeks, chin
• Atopic dermatitis: flexors, hands, feet, face, eyelid

Onset:
• When
• First time
• How long
• Continuous / on and off
• Associated with menstruation

Character
SSSCC
Size
Shape (flat, raised)
Scarring
Color (Red, blackheads, whiteheads)
Content (Discharge: Pus, bleeding, foul smell)

Radiation:
Is it spreading (back, chest, or shoulders )

Associated Symptoms:

Lesion:
• Painful
• Swelling
• Erythema
• Itchiness (how severe?)

Systemic:
• Neurological (Tingling, numbness)
• Joint pain
• Nail changes
• Fever
• Night sweats
• Weight loss
• Loss of appetite
• Recent or current infection

Exacerbating and relieving factors:

• Exacerbating:
• Food (dairy products, fast food)
• Sunlight / UV (sun protection + is your skin sensitive to the sun? Fitzpatrick)
• Cosmetics and chemical exposure (creams or perfumes)
• Weather changes and humidity
• Stress
• Relieved: Moisturising
Severity: Affects daily life, sleep, self-esteem and mood Vision loss and Red-eye
1. WIPPPE (Wash, Introduce, Permission, Privacy, Explain)
2. Patient information: Name and Age
5. PDFS 3. Chief complaint: What brought you here today?
4. SOCRATES
Past medical and surgical history:
• Similar presentation and doctor visit Site:
• Previous investigation (ask about biopsy, imaging, blood transfusion, etc) • Which eye and Unilateral or bilateral
• Previous Hospitalization (ask about radiation, and chemotherapy)
• Previous Surgery or intervention
• Chronic diseases: diabetes, hypertension, dyslipidemia, Cancer Onset:
• Diseases of the system: • When
- Infections: Chickenpox, herpes, URTI, STD • First time
- Dermatology: Atopy (eczema, Asthma, allergic rhinitis), skin condition or cancer • Sudden or gradual
- Hormonal: Insulin resistance, PCOS, endometriosis, Insulin resistance • Continuous / on and off
• Preceding events: Trauma, chemical exposure, migraine
- Autoimmune: RA, SLE, Vitiligo, IBD

Drug History Character:

• Allergy (food or medication) Redness:
• Vaccination (hepatitis) • Bright red
• Are you currently taking any medications: • bluish-red or dark area
- Oral: analgesics, antibiotics, steroids, hormonal replacement, OCP • Injected/ swollen vessels
- Topical: new skincare products, Herbal preparation, new cosmetic products
• Side effects from the medication you currently take? + Specify Type & Dosage & Duration Vision loss: (3C’s)
• Complete loss of vision
Family History: • Central/ peripheral (tunnel vision)
• Similar presentation • Curtain vision
• Chronic diseases: diabetes, hypertension, dyslipidemia, Cancer
• Diseases of the system: Radiation:
- Infections: Chickenpox, herpes, URTI • Pain or swelling around the eye
- Dermatology: Atopy (eczema, Asthma, allergic rhinitis), skin condition or cancer
- Autoimmune: RA, SLE, vitiligo, IBD Associated Symptoms:
Eye: PDF
Social History: • Pain
• Married, children, • Discomfort (itchiness and foreign body)
• Menstrual cycle (regular or irregular) • Discharge (watery, blood, pus)
• Occupation: chemical, radiation, or UV exposure • Fotophobia
• Diet
• Stress and lifestyle
• Vision:
• Pets -ve:
• Smoking - Blurring
• Alcohol - Double vision
• High-risk activities: Drug use and sexual -ve:
• Travel - Floaters
- Halos (around light)
6. ICE
7. Wash hands and thank you If unilateral: Ask if any symptoms are in the OTHER EYE

Done by: Tala Aletani, Arwa Alghamdi, Manar Betar, Elana Hakeem Systemic/ Red flag:
• Headaches
• Night sweats
• Weight loss
• Loss of appetite

Exacerbating & Relieving Factors

 • Exacerbating: 6. ICE
• Movement: Eye movement or standing or exercise 7. Wash hands and thank you
• Light: Dim or bright light
• Irritants: Dust, chemicals
Done by: Tala Aletani, Arwa Alghamdi, Manar Betar, Elana Hakeem

• Relieving:
• Blinking and eyedrop
• Cool/ hot compression

Severity: Affects daily life (work and driving)

5. PDFS

Past medical and surgical history:

• Similar presentation
• Previous investigation (ask about imaging, blood transfusion, etc)
• Previous Hospitalization (ask about radiation, and chemotherapy)
• Previous Surgery (eye surgery or laser) or intervention
• Chronic diseases: diabetes, hypertension, Cardiovascular disease, cancer, infection (URTI,
Herpes, STD)
• Diseases of the systems:
- Eye: previous trauma, refractive error (glasses and lenses), glaucoma, cataract, eye infection,
dry eye
- If the patient wears lenses, ask if they slept in them
- If the patient wears glasses, ask if symptoms get better with glasses
- Autoimmune: Multiple sclerosis, RA, SLE, IBD

Drug History
• Allergy
• Vaccination (hepatitis)
• Are you currently taking any medications:
- Oral: analgesics, steroids, antihistamines, OCP, anticholinergics, medication for heart
conditions or arrhythmia (Amiodorone, ACE- I)
- Topical (eye drops): antibiotics, steroids, prostaglandin, b-blocker, a-agonist, etc
• Side effects from the medication you currently take + Specify Type & Dosage & Duration

Family History:
• Similar presentation
• Sudden early death
• Chronic diseases: diabetes, hypertension, cardiovascular disease, Cancer, infections (URTI,
herpes)
• Diseases of the system:
- Eye: Blindness, refractive error (glasses and lenses), glaucoma, cataract, keratoconus, dry
eye
- Autoimmune: Multiple sclerosis, RA, SLE, IBD

Social History:
• Married, children
• Occupation: chemical exposure and UV
• Stress
• Diet and lifestyle (driving)
• Smoking
• Alcohol
• High-risk activities: Drug use and sexual
Eye exam: II. Ishihara Chart:
Not done in the OSCE settings just verbalize it.
Optic Nerve Exam (CN 2):
6 things you have to do: III. Visual Fields:
• 2 Charts 1. Sit directly facing the patient, your faces should be at the same level, and approximately 1
• 2 Fingers meter away.
• 2 Devices 2. Ask the patient to close one eye, if you are testing the patient's right eye, close your left
eye. (mirror the patient)
2 Charts: 3. Ask the patient to fix his eye on one point. “Keep your eye fixed on my nose and do not
• Snellen Chart (Visual Acuity) move his head or eyes”.
• Ishihara Chart (Color Vision) 4. Ask the patient to tell you when they can see your fingertip wiggling.
5. Starts from the outer quadrants and bring your finger slowly inwards to the center.
2 Fingers: 6. Repeat this process in each 4 quadrants and in both eyes
• Visual Fields 7. If you can see your fingertip but the patient cannot, this would suggest a reduced visual
• Accommodation field.

2 Devices:
• Light Reflex (Direct/consensual and swinging light for RAPD) IV. Accommodation:
• Fundoscopic Exam 1. Ask the patient to focus on your finger.
2. Then slowly bring it closer in front of their nose.
Inspection: 3. Inspect for normal response: pupillary constriction and convergence.
Eyelids: Ptosis
Pupils:
• Size (normal size of pupils is 2 - 4 mm) V. Light Reflex:
• Shape Afferent: CN II, Efferent: CN III. Normal: both pupils constrict whether direct or consensual
• Symmetry (misalignment, strabismus) response.

I. Snellen Chart (Visual Acuity):
1. Ask the patient to sit 20 feet or 6 meters away from the chart
2. If the patient wears eye glasses, ask them to put them on before
you start your assessment
3. Examine one eye at a time: ask them to cover the affected eye
first (examine the normal eye, then the abnormal)
4. Record your findings: distance over the lowest line read.
- OD: Right eye
- OS: Left eye
- OU: both eyes
- CC: With correction glasses
- CS: Without correction glasses
Pediatric Visual Acuity Assessment:
0-2 Months: Blinking to light
2 Months - 2 Years: Fixation on an object
2 Years - 5 Years: Allan Picture Chart
> 5 Years: Snellen Chart (if they know letters)
Direct reflex: Shine the light from the side (to avoid pupillary constriction in response to
accommodation) → look for pupillary constriction in the same eye.
Consensual reflex: shine torch into eye → look for pupillary constriction in opposite eye.
Swinging light test: move light in from side of each eye rapidly to detect relative afferent
pupillary defect RAPD, the affected eye will dilate.
Extra information about Relative afferent pupillary defect (RAPD):
• Becomes obvious with the swinging flashlight test.
• When light is shone on the normal eye, both will constrict.
• When light is removed from normal eye to affected eye, pupil with RAPD will paradoxically
dilate.
• Lesion: optic nerve (Afferent). Most common cause: demyelination from multiple sclerosis.
A 30/20 vision means that this
patient can see at 20 feet what
a normal person can see at 30.
VI. Fundus Exam (Posterior Segment): Extra-Occular Muscles Exam (CN 3,4,6):
Be in the same level as your patient, & hold his head with your other hand to stabilize it.
(Examine the Right eye with your Right eye and your Right hand and vice versa) 3 things you have to do:
• 2 Fingers
1. Ask the patient to look at a distant target (important) • 1 Devices
2. Dim the lights so pupils dilate.
2 Fingers:
3. Turn on the fundoscope, adjust the focus until you can clearly see
4. Mention that you can see the red reflex (Absent red reflex: Cataract or retinoblastoma) • Extra-occular movements
5. Move in closer & examine the eye with the fundoscope • Accommodation
Tip: Begin medially and follow any artery you see to the center, it will guide to the optic disc. 1 Device:
Inspect the funds and comment on the following: • Light Reflex (Direct/consensual and swinging light for RAPD)
1. The optic disc: color/contour/cupping
2. Retinal vessels: cotton wool spots, AV nipping, or neovascilarization Inspection:
3. Macula: Ask the patient to look directly at the light. Druses might be noted in macular Eyelids: Ptosis
degeneration Pupils:
• Size
Abnormalities: • Shape
• Absent red reflex: may indicate the presence of cataract, or in rare circumstances • Symmetry (misalignment, strabismus)
neuroblastoma
• Papilledema: hazy margins
• Optic atrophy: well-demarcated margins, including the nasal side of the disc, which
I. Extra-Occular Movements:
• should be hazy normally. You are assessing for:
• Failure of movements
• Double vision
• Nystagmus
Steps:
1. Ask the patient to follow your finger with their eyes, the head should not move.
2. Move your fingers in an H shape + Obliquely and assess all eye movements.
3. Make sure the patient is following your finger to the maximum all the way until you can no
longer see the whites of their eye at the corner.
4. Ask if double images are seen in any direction.

II. Accommodation:
Explained above.

III. Light Reflex:

Explained above.
Ear exam: EXTRA: “I would use pneumatic otoscope or ask the patient to perform the valsalva
maneuver while the otoscope is inside to check mobility of the tympanic membrane”
Don’t forget to wear gloves
Inspection: before examining the patient.
SEADS
Skin changes
Special Tests:
Erythema
Pre-Auricular sinus/pits
• Rinne & Webber
• Facial Nerve Exam
Discharge or bleeding
Deformity Rinne Test:
Swelling or masses in the pre/postauricular area Examine each ear in turn:
Size and shape of the pinna 1. Placing the vibrating tuning fork against the patient's mastoid bone and asking the patient
to tell you when the sound is no longer heard.
Palpation: 2. Once the patient signals they can't hear it, the still vibrating tuning fork is then placed 1–2
Palpate for any tenderness, masses, pain cm from the auditory canal.
• Lobule 3. The patient is then asked again to indicate when they are no longer able to hear the
• Tragus tuning fork.
• Auricle / Pinna
• Pre-auricular & Post-auricular area Results:
• Mastoid Process • Patient with normal hearing or sensorineural hearing loss will perceive the tone as louder
in front of the ear (+ve Rinne)
Otoscope (Range of Motion): • In conductive deafness, the sound is heard best at the mastoid process (-ve Rinne)
1. Turn on the otoscope and ensure the light is working and put a plastic tip
2. Hold the otoscope like a pencil in your right hand for the patient’s right ear & vice versa.
3. Rest your hand against the patient’s cheek for stability. Webber Test:
4. Gently pull the ear upward and backward to straighten the ear canal (in children only pull After striking the 512 Hz tuning fork, Put the vibrating tuning fork on the center of a patient's
out backward) forehead. Ask the patient if the sound is louder in one ear, and if so, which one.
5. Gently insert the Otoscope while supporting your hand with your little finger against the
patient’s face (say it). Results:
6. Inspect and comment on the following features in both the external auditory canal and the Normal result: The sound can be heard equally in both ears
tympanic membrane Abnormal result: (you will know if it is conductive or sensorineural from Rhine test)
7. Mention again that you will compare to the other side
• In conductive deafness, sound is loudest in abnormal ear
• In sensorineural deafness, sound is loudest in normal ear
Inspection of the external auditory canal:
SEADS
Skin changes Facial Nerve Examination:
Erythema • First inspect the patient’s face for facial asymmetry
Pre-Auricular sinus/pits • Ask the patient to smile
Discharge or wax impaction • Ask the patient to puff out their cheeks against resistance
Swelling, masse, or foreign body • Close their eyes and keep them closed against resistance

Commenting on the tympanic membrane:

PROTECT
Conclude all ENT exams by saying:
Perforation • I will perform a full cranial nerve exam.
Reflex (Light Reflex)/ Retraction • I will perform a full ENT exam.
Ossicle (Malleus) • I will perform a cervical lymph node exam
Thickness
Effusion
Color of TM (Pearly)/ Cholesteatoma
Tympanostomy Tube (Grommet tube)
Neck Exam: Percussion:
Check for retrosternal dullness:
Inspection: Begin superiorly from the sternal notch and go downward over the manubrium
SEADS - Normal: Resonant
Skin changes - Retrosternal extension: Dullness
Erythema
Atrophy of Sternocledomastoid
Deformity Auscultation:
Symmetry Ask the patient to hold their breath and auscultate each lobe of the thyroid for bruit by the
Swelling or masses BELL for 10-30 seconds (increased vascularity; thyrotoxicosis-graves)
- Ask the patient to swallow & protrude their tongue
Special Test:
Palpation: 1. Pemberton’s Sign: Ask patient to raise arms above head ➔ Positive if face becomes
Thyroid: swollen and red, retrosternal goiter occludes neck veins.
Stand behind the patient and ask the patient to flex their neck and with your thumb on 2. Proximal myopathy: Ask the patient to stand from a sitting position with arms crossed on
the occiput from behind palpate for: the chest (if unable; Hyperthyroid).
3Ts:
Tenderness
Temperature Peripheral Exam:
Thrill Hands:
• Palpate each lobe while pushing on the opposite lobe to make it more prominent. • Clubbing
• Ask the patient to swallow and protrude their tongue and feel the gland again for masses • Onycholysis
and comment if it moves or not with swallowing and tongue protrusion. • Erythema, wet & warm hands OR cold & dry hands
• Muscle wasting

Cervical Lymph Nodes:

• Fine tremors
• Pulse
• Use gentle rotating movement using the fingertips.
• Make sure the patient maintains a neutral head position to not tense the SCM. Face:
• With the up and down technique palpate the following lymph nodes (all of them): Forehead: sweating
- Submental Eyebrows: loss of outer 1/3 of eyebrows
- Submandibular Eyes:
- Pre/post auricular
- Parotid gland • Lid retraction (Inspect anteriorly)
- Anterior cervical (anterior to SCM) • Exophthalmos (Inspect sides)
- Posterior cervical (posterior to SCM) • Lid Lag
- Supraclavicular • Ophthalmoplegia (H movement)
- Infraclavicular
- Occipital nodes Mouth:
Hoarseness (vocal cord paralysis, rises suspicion of thyroid malignancy)
If a lymph node is palpable, don’t forget to comment:
Site, size, shape, surface, consistency, tenderness, and if it’s single or multiple. Lower Limb:
Edema: Pretibial myxedema vs non-pitting edema
Reflexes: Hyerpreflexia (Hyperthyroidism) va Delayed relaxation (Hypothyroidism)
Trachea:
By placing your index and ring finger on the the clavicle and assessing the
tracheal deviation by your middle finger one side of the trachea and check Conclude all ENT exams by saying:
for any space between it and the sternocleidomastoid (SCM) muscle. • I will perform a full cranial nerve exam.
• I will perform a full ENT exam.
Carotid Pulse • I will perform a cardiovascular and abdominal exam
Oral Cavity Exam: Palpation:
Bimanual examination:
Equipment: YOU MUST WEAR GLOVES
• Torch Palpate using one finger palpating the inferior jaw/chin externally
• Tongue Depressor and the other gloved finger in the oral cavity and palpate for the
• Gloves following for any lumps from both sides:
1. Lateral wall of the mouth: Parotid gland and duct
Inspection: 2. Floor of the mouth: Submandibular gland and sublingual gland
You will say all the following for all parts of the mouth mentioned down: gingiva, tongue… 3. If any intraoral swelling present, comment on site, size, shape,
SEADS - CLU surface, color, consistency and tenderness
Swelling or masses
Erythema
Cervical Lymph Node Exam:
Angular stomatitis/ Asymmetry
Deviation / Discharge
• Use gentle rotating movement using the fingertips.
• Make sure the patient maintains a neutral head position to not tense the SCM.
Stones • With the up and down technique palpate the following lymph nodes (all of them):
- Submental
Candida - Submandibular
Leukoplakia - Pre/post auricular
Ulceration - Parotid gland
- Anterior cervical (anterior to SCM)
Asses mouth opening for: pain and trismus - Posterior cervical (posterior to SCM)
- Supraclavicular
Use tongue depressor and assess all the following landmarks (either single to two depressors). - Infraclavicular
In each of the 4 parts mention (SEADS CLU): - Occipital nodes

1. Anteriorly:
• Lips Conclude all ENT exams by saying:
• Gingiva • I will perform a full cranial nerve exam (including facial nerve & fiberoptic scope).
• Alveolar margins • I will perform a full ENT exam.
• Teeth: missing teeth, nicotine staining, decay
• Tongue: glossitis

2. Lateral Wall of The Mouth:

• Buccal mucosa
• Stensen’s duct (opening for parotid gland)

3. Floor of the mouth:

• Opening of the submandibular and sublingual gland

4. Roof of the mouth:

• Hard palate
• Soft palate
• Pharyngeal arches (Pillars)
• Uvula
• Tonsils
• Peritonsilar abscess (if present)
Nasal Exam: Special tests:
1. Cold spatula mist test:
Tools: Ask the patient to breath out against a cold
stainless-steel spatula and look for bilateral
• Head light / Pen light mist. This indicated normal patency.
• Nasal speculum

2. Cotton wool whisp test:

Inspection: A fluff of cotton is held against each nostril and its movements
External Nose: indicate the nasal blow of air while the patient inhales or exhales. Make sure
Inspect from the front, sides, & back. to close the opposite nostril.
SEADS
Skin changes, Scars, Swelling
Erythema 3. Cottle’s test:
Alignment The cheek is pulled away from the midline with the physician's index finger
Deformity to increase the nasal valve angle. A positive Cottle sign is present when this
Symmetry (from the back and tilt the patient head) maneuver improves nasal breathing.

Vestibule:
Lift the tip of the nose while using a light source and comment on: 4. Transillumination Test
• Septum Done for the maxillary and Frontal Sinuses.
• Crusting Maxillary: place the light source on the maxillary sinus and
• Furuncles look for the transillumination of the light inside the oral cavity.
Frontal: place the light source on the superiomedial angle of
Palpation: the orbit and view the transmission of light in the frontal sinus.
Comment on all of the following:
Normally you’ll see the illumination of the light in the oral cavity
• Temperature or the forehead indicating that the sinuses are free of signs if
• Tenderness inflammation/infection.
• Crepitation
1. Nasal bones & cartilage 5. Smell test:
2. Infraorbital ridges • Ask the patient to close his eyes.
3. Paranasal sinuses assessing maxillary and frontal sinuses • Use different substances such as: clove oil, peppermint, coffee, rose essence, Lemon.
• Assess whether the patient can differentiate the different scents

Anterior Rhinoscopy (Range of Motion):

• Ask the patient to look forward, keeping their head in a neutral position. Conclude all ENT exams by saying:
• Carefully elevate the tip of the nose with your thumb, so that the nasal cavity becomes • I will perform a full cranial nerve exam.
visible. • I will perform a full ENT exam.
• Using a light source to externally illuminate the cavity and gently insert the speculum • I will perform a cervical lymph node exam
horizontally while it’s closed with your non-dominant hand. • I will perform posterior rhinoscopy.
• Inspect:
1. Nasal vestibule: patency of the nasal cavity
2. Nasal mucosa: color (normal is pink), ulceration, edema, purulent discharge
3. Septum (medially): mucosal covering, deviation and perforation
4. Turbinates & Masses (laterally): inferior turbinate inflammation/hypertrophy, polyps
Red Eye / Vision Loss: Past Medical History:
• Surgeries: Laser surgery
Site: • Trauma: History of trauma to the eye
Unilateral vs Bilateral • Chronic disease: DM, HTN, Cardiovascular disease, Atopy, Autoimmune disease,
Malignancy
Onset: • Similar disease: Refractive errors, contact lens or eyeglasses wear, glaucoma, cataract
• When did it start? • Infections: URTI or eye infection
• Sudden or gradual
• Continuous or intermittent? Family History:
• Similar compliant: Sudden vision loss or blindness
Character: • Chronic disease: DM, HTN, Cardiovascular disease, Atopy, Autoimmune disease,
Red Eye: Malignancy
What is the color like? • Similar disease: Keratoconus, refractive errors, glaucoma, cataract
• Bright red • Infections: URTI or eye infection
• Bluish-red or dark area
• Injected vessels Social History:
• Can you still drive?
Vision Loss: • Where do you live and do you have pets at home?
Pattern of Vision Loss: • Sexual activity
3Cs
Complete
Curtain
Central vs Peripheral (tunnel vision)

Type of Vision Loss:

BCD
Bluriness / Haziness
Color blindness
Distance dependent (important)

Radiation:
• Is there associated eye pain? And does it radiate elsewhere?
• Is there redness in the eye?
Associated Symptoms:
PDDDF + Headache
Photophobia
Diplopia (double vision)
Discomfort (foreign body, itchiness)
Discharge (watery or mucous-like)
Floaters or Halos
Headaches

Exacerbating Factors:
Light: dim vs bright light
Movement: eye movements or vigorous exercise

Relieving Factors:
Eye drops, cool/warm compress
Nasal Congestion / Epistaxis: Past Medical History:
• Surgeries: rhinoplasty or septoplasty (Post-Op Complication: Profuse bleeding)
Site: • Trauma: History of trauma to the face
• Unilateral vs Bilateral OR Does it alternate? • Chronic disease: DM, HTN, Cardiovascular disease, Atopy, Autoimmune disease,
• If Epistaxis: Anterior vs posterior epistaxis Malignancy
- Anterior: blood drips anteriorly through the nostrils • Similar disease:
- Posterior: blood drips backwards to the throat - ENT: Nasal septal deviation, nasal polyps, or rhinosinusitis
- Hematology: Platelets disorder, bleeding disorder, or leukemia
Onset: • Infections: Recurrent URTI
Did the congestion/bleeding start after the following risk factors?
STUFfy nose, EW! Durg History:
Stress (emotional or physical) • ENT: Intasnasal Spray (steroids, normal saline or decongestant)
Trauma (nasal/facial fractures or nose picking) • Hematology: Anti-platelets or anti-coagulants (Aspirin or Warfarin)
URTI (rhinitis, sinusitis)
Foreign body Family History:
Exercise • Similar compliant
Weather (hot weather, under the sun) • Chronic disease: DM, HTN, Cardiovascular disease, Atopy, Autoimmune disease,
Malignancy
Character: • Similar disease:
FACC: - ENT: Nasal Septal deviation, nasal polyps, or rhinosinusitis
Frequency - Hematology: Platelets disorder, bleeding disorder, or leukemia
Amount • Infections: Recurrent URTI
Color
Content (blood clots) Social History:
• Where do you live and do you have pets at home?
Bleeding: • Use of drugs (sniffing cocaine).
• Is there bleeding from any other orifice? (Hemoptysis, hematemesis, blood in stool)
• Do you bruise easily?
Radiation:
• Is there associated pain?
Associated Symptoms:
EENT + Face
Eye: Eye redness or discomfort
Ear: Ear pain or discharge
Nose: Foul smell, loss of smell, snoring (obstruction)
Throat: Dysphagia or sore throat
Face: Facial pressure/pain or headache (sinusitis)

Exacerbating / Relieving Factors:

Weather: hot/cold or dry/humid
Irritants: smoking, dust
Skin Rash History (Acne & Atopic Dermatitis): Past Medical History:
Investigations: Skin biopsy
Chronic Diseases: Skin cancer (+ ask about usual chronic diseases, including autoimmune)
Onset:
Similar Diseases:
Is it associated with your menstrual cycle? (Cyclic pattern)
- Acne: PCOS, Obesity, insulin resistance, or any other skin condition
- Atopic Dermatitis: eczema, asthma, allergic rhinitis, or any other skin condition
Character:
Infections: Skin infections (chickenpox or herpes) & URTI.
SSSCC
Size
Drug History:
Shape (flat, raised)
Scarring • Steroids
Color (Red, black heads, white heads) • Antibiotics
Content (Contains Pus)
• New skincare products
Family History:
Radiation: Chronic Diseases: Skin cancer (+ ask about usual chronic diseases, including autoimmune)
• Is it painful?
Similar Diseases:
• Has it migrated (radiated) or spread to another area? (Chest, Back, Shoulders) - Acne: PCOS, Obesity, insulin resistance, or any other skin condition
- Atopic Dermatitis: eczema, asthma, allergic rhinitis, or any other skin condition
Associated Symptoms: Infections: Skin infections (chickenpox or herpes) & URTI.
BIRDS
Bleeding
Social History:
Itchiness
• Where do you live and do you have pets at home? (Animal Contact)
Rash
• Depression: Have you experienced low mood or loss of interest lately?
Discharge / Dryness - Do you feel that this skin lesion has affected your self-esteem & confidence?
Sensation (tingling, numbness, or other neurologic symptoms)

Exacerbating & Relieving factors:

• Exacerbated by allergens or irritants? (such as perfumes or pets)
• Exacerbated by winter & dry skin?
• Relieved by creams or medications?

Severity:
• Does it affect your daily activity? (Work/school or Sleep)

Risk Factors:
SCReW DSM-5 (5 looks like S)
Sun exposure (exposure to heat & humidity)
Chemical exposure
Radiation exposure
Work exposure (Occupation Exposure)

Diet (high glycemic index food or skimmed dairy products)

Stress
Medications: steroids
Skincare: Comedogenic skin products
Insomnia History: PAM:
Psychosis:
Onset: • Hallucinations: “Have you ever heard voices speaking when there’s no-one around?”
When did the problem start? • Delusions: “Have you ever felt that someone is able to put thoughts into your head?”
• Paranoia: “Do you fear that people are out to get you?”
Character (Sleep Character): Anxiety: “Have you felt more anxious lately” & “have you noticed that your muscles are
1- Before Sleeping: tense”
Sleep Schedule:
Mania: “Have you experienced periods where you feel euphoric/energetic?”
1. What time do you go to sleep (weekdays vs weekends)?
2. How long does it take you to fall asleep?
- If you wake up at night, how long does it take you to go back to sleep?
Past Medical History:
Sleep Hygiene: Investigations: Sleep study
1. Food: do you eat heavy meals before sleeping? Chronic Diseases: Hypo/Hyperthyroidism (+ ask about usual chronic diseases, including
- Do you consume a lot of caffeine or energy drinks? (How many cups of coffee per day) autoimmune)
2. Exercise: do you perform vigorous activities late at night? Similar Diseases:
3. Sleep environment: noise, light, temperature, cell phone in the bedroom, partner in the room
- Psychiatric: Depression, generalized anxiety disorder
- Sleep Issues: Narcolepsy, OSA
2- While Sleeping:
1. Is your sleep continuous or interrupted?
- If interrupted, What’s the frequency and the trigger (toilet or nightmares)? Drugs History:
2. OSA symptoms: snoring loudly, gasp, choke, or stop breathing during sleep Stimulating antidepressants: Fluoxetine
3. Leg movement during sleep: legs jerk or uncomfortable feeling in the legs, relieved by Sedating Drugs: Benzodiazepines and antihistamines
moving the legs.
4. Sleep walking
Family History:
3- After Sleeping: Similar compliant: insomnia
1. When do you wake up? Chronic Diseases: Hypo/Hyperthyroidism (+ ask about usual chronic diseases, including
2. After waking up, do you feel fresh or exhausted? autoimmune)
3. Do you have headaches or dry mouth? Similar Diseases:
4. Having difficulty staying awake during the day (such as while driving) or falling asleep in - Psychiatric: Depression, Generalized anxiety disorder
quiet places? - Sleep Issues: Narcolepsy, OSA

Associated Symptoms: Social History:

Depression: Occupation: Nature of the job and relation to sleep? (WHACS)
MISGECAPS - Shift job: e.g. ER or Pilot
• Mood is depressed - Stress
Ask about depressed mood &
• Interest loss interest first:
• Sleep disturbance
• Guilt If the patient doesn’t have any of
them, do not continue with the
• Energy decline
depression questions, move on to
• Concentration difficulties PAM to save time.
• Appetite or weight changes
• Psychomotor abnormalities
• Suicidal ideation - If yes:
- Did you prepare a plan?
- Have you had any previous attempts?
5/9 symptoms must be present for 2 weeks (M or I must be present).
Limb Weakness: Headache:
Site: Site:
Where exactly is the pain, is it unilateral or bilateral? Where exactly is the pain, is it unilateral or bilateral?

Onset: Onset:
When were you last seen normal? Have you noticed that anything in specific triggered your headache?

Character: Character:
What is the character of the pain/discomfort: sharp, burning, cramping or tight pain. What is the character of the pain: pulsating, throbbing, pounding, or worst headache of their
life?
Radiation:
• Does the pain radiates/moves elsewhere? Radiation:
• Headaches, neck pain, back pain? Does the pain radiate to the neck?

Associated Symptoms: Associated Symptoms:

Special Senses gave me a MAD FLU Before Headache/auras:
Visual hallucinations (zig-zag lines, flashing lights, blind spot)
Special Senses: loss of vision, hearing, smell, taste, touch (loss of sensation)
Mental Status & Memory (Cognitive dysfunction) During Headache:
Atrophy & weakness in limbs Migraine:
Dizziness & Dysphagia POUND
Fasiculation Photophobia & Phonophopbia
Language: Slurred Speech One day duration
Urinary incontinence Unilateral
Nausea & Vomiting
Disabling
Past Medical History:
Head Trauma
Other Differentials:
Chronic Diseases
Just FRENDS
Similar Diseases: Stroke, TIA, multiple sclerosis
Jaw Claudication
Infections: meningitis and encephalitis
Facial Pain
Rhinorrhea
Family History: Eye: Lacrimation & Blurry Vision
Chronic Diseases Neurologic Deficits: loss of consciousness, loss of sensation, or limb weakness
Similar Diseases: Stroke, TIA, multiple sclerosis Dizziness
Infections: meningitis and encephalitis Stiff Neck (Neck Pain)

Time:
Worse in early morning?

Exacerbating & Relieving Factors (Triggers):

Triggers:
- Specific food (3 Cs: chocolate, cheese, caffeine - Migraine)
1. You eat (food)
- Vigorous exercise (Migraine)
2. Then go to the gym (vigorous exercise)
- Touching scalp (Temporal arteritis)
3. Then take a shower (touching scalp)
- Position (Brain tumor)
4. Then lie down (position)
- Sleep deprivation
5. Then finally sleep (sleep deprivation)
Past Medical History: Depression:
Investigations: Lumbar puncture
Trauma: Head trauma Onset:
Chronic Diseases: Brain tumors • When did it start?
Similar Diseases: Migraines, stroke, multiple sclerosis • Sudden or gradual?
Infections: meningitis and encephalitis • Continuous or intermittent?
• Was there any trigger for those feeling?
• Do these feelings suddenly come before your menstrual cycle begins?
Drug History:
• NSAIDS
• Steroids Associated Symptoms:
• Blood thinners (Aspirin) Depression:
• OCPs MISGECAPS Mania Symptoms:
DIG FAST
• Mood is depressed Distracted easily
• Interest loss Impulsivity / Irritability
Family History: • Sleep disturbance
Anyone in the family with a similar presentation? Grandiosity (Special Power)
• Guilt
Chronic Diseases: Brain tumors • Energy decline Flight of Ideas
Similar Diseases: Migraines, stroke, multiple sclerosis • Concentration difficulties Activity Increased (euphoric / energetic)
Infections: meningitis and encephalitis • Appetite or weight changes Sleep Deficits
• Psychomotor abnormalities Talkativeness
• Suicidal ideation - If yes:
- Did you prepare a plan?
- Have you had any previous attempts?
5/9 symptoms must be present for 2 weeks (M or I must be present).

PAMM:
Psychosis:
• Hallucinations: “Have you ever heard voices speaking when there’s no-one around?”
• Delusions: “Have you ever felt that someone is able to put thoughts into your head?”
• Paranoia: “Do you fear that people are out to get you?”
Anxiety: “Have you felt more anxious lately” & “have you noticed that your muscles are
tense”
Mania: ask ALL mania symptoms
Medical Conditions:
• Cold intolerance, dry skin, weight gain (Hypothyroidism)
• Palpitations, SOB, fatigue (Anemia)

Exacerbating & Relieving Factors:

• Worse: with life-stressors (marital dispute, social life, financial stress)
• Relieved by: self-harm / self-destructive behavior (cutting wrists or thighs)
Past Medical History:
• Hospitalization: Due to suicide attempt
• Chronic Diseases: Hypothyroidism & Anemia
• Similar disease: Psychiatric disorders (MDD, GAD, Bipolar)

Family History:
• Chronic Diseases: Hypothyroidism & Anemia
• Similar disease: Psychiatric disorders (MDD, GAD, Bipolar)
• History of suicide

Social History:
• Food: Caffeine intake
• Stressors
• Support system: how’s your relationship with your family and friends?