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ROD’S AMC 2 CLINICAL: CATCH ALL 1 PAGE FORMAT

HPC:
SOCRATES site, onset, character, Radiation, Associated factors, Timing, Exacerbating Associated Symptoms: screening questions
(relieving), Severity HEENT: Headache or dizziness, pain/ stiffens in the neck, sore throat, cold or flu like symptoms
Site: where exactly do you have the pain? RESP SYS: cough or cold, SOB, fever, haemoptysis
Onset: how did it start- sudden or gradual? Is it getting worse? CARDIO: racing heart, chest pain, pressure in the chest, swelling/ pain in the legs, fainting
Character: what is the nature of the pain- burning, throbbing, dull ache? GASTRO: Abdominal pain, bloating and swelling, nausea, diarrhea or constipation, jaundice,
Radiation: does the pain go anywhere else? fever, LOA, LOW
Associated symptoms ENDOCRINE: weather preference, tremors, tiredness, changes in bowel movements
Timing: continuous/ on and off? Any variation with day and night? DERM: Itching, Rash, Ulcers, Discoloration, Dryness, Scab, Discharge.
Exacerbating/ relieving factors: does anything make it better or worse? Lump/lesion Ax: Site, Size, Shape, Surface + Consistency, Compressibility, Colour, Contour (4Ss-
Severity: how severe the symptom is? 4Cs) + Fluctuation, Mobility
Previous Diagnosis questions: Genitourinary: Dysuria (burning sensation), Frequency (do you have to go to the restroom
When were you diagnosed? What medicines were you prescribed? Compliance: Are you taking more often), Nocturia (do you have to go to the restroom more often at night) Hesitancy (is it
them regularly? Any side effects/ Complications of the disease? When was the last visit to the difficult to start the stream), Poor stream, Discharge from private parts Rash/ soreness/ ulcer
specialist? Lumps or bumps
Bodily fluids: For vomiting, diarrhoea, urine symptoms, genital discharge, phlegm, bleeding Musculoskeletal: Pain, Stiffness, Deformity/Weakness, Swelling: Redness, Temperature and
and discharge from any site, ask CCOV questions: Tenderness (Tumor, Rubor, Calor, Dolor) Nodules (lumps/bumps) Rash/ ulcers Inflammatory
Colour features: red eyes, mouth ulcers
Consistency Nervous System: Local: Burning pain, Weakness, Numbness, Tingling Central: Cauda equina
Odour syndrome (problems with passing stool or urine) Headache Stroke/TIA: problems with vision,
Volume swallowing, speech, gait, Seizures/ fits, Early morning vomiting, Neck stiffness
General: LOA, LOW, fever, rigors, chills night sweats, joint pains,
HISTORIES Physical Examination Findings From Examiner (PEFE)
Past Medical History/ Surgical History: Hemodynamic stability
Have you been diagnosed with any significant illnesses (high blood pressure, high sugar, General Appearance: PRICCLED Pallor, Rash, Icterus, Cyanosis, Clubbing, Lymphadenopathy,
bleeding disorder, congenital problem) Any surgery or procedures? Oedema, Dehydration
Psych: past history: thyroid problems, head injury, infection Past h/o: mood disorders, Vitals: BP with postural drop, Heart rate, Temp, O2 sats, respiratory rate
hospitalization, suicide attempts Systems review starting with affected system
Family History Office tests: ECG, BSL, Urine dipstick, fundoscopy, Urine Pregnancy Test: Urine dipstick:
Is there a family history of… bleeding, HTN, Arthritis, asthma leucocyte esterase & nitrites (infection), ketones (dehydration), glucose, blood, proteins
Psych: history of SADDD: suicide, alcohol, drugs, depression/MH, divorce Physical Examination
Social History WIPEC: Wash hands, Introduce, Patient name, Explain, Consent
LOW-ASSS: Living situation, Occupation, Worries (or problems), Activities (Appetite), Sleep, PE approach: inspection, palpation, percussion, and auscultation. In ABDO: Inspection,
Sexuality, Safety auscultation percussion and palpation.
SADMACT: Smoking, Alcohol, Drugs, Medications, Allergies, Contacts, Travel NEURO: CN I-XII + UL/LL: ITPRCS: inspect, tone, power, reflexes, coordination, sensation
MSK: Look, Feel, Move, Special tests (LFM-ST)

PSYCHIATRIC OBGYN PEDIATRIC

ORGANIC DDX: 5 Ps BINDS
Thyroid: have you had any changes in your bowel function? 1 Periods Birth/pregnancy
Do you have any weather preferences/feel hot or cold ? Duration Immunisations
Intermenstrual spotting/ bleeding
Infection: Any fever, cough or cold? Pain
Nutrition
Head injury: Have you ever injured your head before? Volume Development
Depression: MSIGECAPS 2 Partner Siblings- social dev
M –Mood, S – Sleep, I – Interest, G – guilt, E – energy, C – 3 Pregnancy (miscarriage/ abortions)
concentration, A – Appetite, P psychomotor, S – Suicide 4 Pill/ contraception Sick Child Questions
depression symptoms 5 Papilloma cervical screen/ (Gardasil vaccine) Drowsy, active, irritable
ASEPTIC-JR Feeding difficulty/ appetite
Appearance: posture, clothing, facial expression First trimester Questions Reduction in urine output
Behaviour: Appropriate/not; Abdominal pain Problem with passing urine and stools
restlessness/agitation/depressed/retarded/withdrawn Vomiting
Co-operation Breast tenderness
Eye contact Bleeding / discharge Growth charts
Speech: volume; tempo, rate LMP / any issues
Emotions: mood, affect Iron and folic acid
Perceptions: Hallucinations can you see or hear things Blood group Tiredness: HEMIFADO
others don’t Prenatal tests: FBE, blood group and Rh factor, BSL, urine Hepatic pathology - changes in the skin color, tattooing, iv
Thoughts: dipstick and urine microscopy culture and sensitivity, UEC, drug use?
Delusions: reference, grandeur, persecution, vitamin D estimation, rubella, varicella serology and STI Endocrine (hyperthyroidism /hypothyroidism,DM, adrenal
guilt do you sometimes hear people talking about you screening. insufficiency (Addison’s)
or plotting against you? do you feel guilty? Folic acid 0.5mg for the next three months. Malignancy - lumps or bumps anywhere in the body, fever
WEBI: anyone controlling mind: withdrawal, Third trimester Questions: Infections (HIV/TB/Subacute Bacterial Endocarditis,) - sexual,
echoing, broadcasting, insertion Foetal movements: average 10 per day travel history
Insight: need medical help Abdominal pain F - Chronic Fatigue syndrome - feeling tired? Recent viral
Cognition: orientation Bleeding / discharge infection
Judgement: room is on fire Pre-eclampsia: headache, visual disturbance, persistent Anemia - pallor, sob, fatigue
Risk: suicidal/ homicidal ideation, home safety swelling of legs Drugs- (methamphetamine---ice/shabu - agitation, loss of
Vaginal bleeding: appetite, psychosis, lack of sleep)
Memory: Short term: forgetting PALM COSIE Others (depression, eating disorders, coeliac disease, IBD,
• People’s names, turn off the stove, The way back home P --> Polyps, pregnancy special diet MH)
• Misplacing keys A --> Adenomyosis/ Endometriosis
Long term: remember childhood/ important events from past L --> Leiomyomas (fibroids)
M --> Malignancy or hyperplasia Post partum check
C --> Coagulopathy 4 B's to check in post-partum:
O --> Ovulatory dysfunction 1. Baby
S --> STI, cervicitis, PID 2. Breast
I --> Iatrogenic e.g medications, hormonal therapy 3. Bladder
E --> Endocrine: thyroid 4. Birth canal
Key milestones in pregnancy:
8W dating Scan (viability and site)
10W NIPT non-invasive prenatal test to look at the genetic
material of the baby. Detection rate for NIPT is 99%.
W12 Blood Tests + nuchal translucency, Morphology US
W18/20, 26/28 W Sweet drink, US W32, BUG test 36W

Management/ Next Steps

• Invx r/o other causes: FBE, U&E, LFTs, ESR/CRP, lipase, x CXR, ABG/ VBG,
• Infection screening: blood MCS urine MCS, CXR, LP + all of the above
• Meds
• Lifestyle modifications
• 3 Rs: Referral : Reading materials: Red flags