1. Step 6
1.1. Review session 1
1.2. Report new knowledge
1.2.1. Physiology
1.2.1.1. sperm production
1.2.1.2. ovum production
1.2.1.3. conception
1.2.2. Common fertility dysfunction in males and females
1.2.2.1. Male factors
1.2.2.2. female factors
1.2.2.3. both
1.2.2.4. idiopathic
1.3. 30 minutes
1.4. The scribe doesn't have to write in this step
2. Step 8
2.1. Diagnostic decision
2.1.1. Wife
2.1.1.1. PCOS
2.1.2. Husband
2.1.2.1. abnormal sperms
2.2. Mechanism
2.2.1. Wife
2.2.1.1. High FSH, low LH
2.2.2. Husband
2.2.2.1. pests exposure
2.2.2.2. smoking
2.2.2.3. alcohol
2.3. Presentation
2.3.1. Wife
2.3.1.1. irregular cycle
2.3.1.2. acne
2.3.2. Husband
2.3.2.1. varicocele
2.4. Supporting data
2.4.1. Wife
2.4.1.1. cysts in ovaries
2.4.1.2. laparascopy
2.4.1.2.1. pelvic inflammatory disease
2.4.2. Husband
2.4.2.1. sperm specimen taken with abnormal results
2.5. 10 minutes
3. Step 7
3.1. Inquiry plan and info gathering
3.1.1. History of presenting complaint
3.1.2. Previous medical / surgical history
3.1.2.1. husband
3.1.2.1.1. arrived from italy since 8
3.1.2.1.2. no history of infections or sexual experience
3.1.2.1.3. worked in farm growing fruit trees with many chemicals including pesticides and fruit collection
3.1.2.1.4. had no sexual education before
3.1.2.1.5. feels pressure by his parents to have a child
3.1.2.2. wife
3.1.2.2.1. wife had irregular periods since age of 13
3.1.2.2.2. took pills to regularize her peroid
3.1.2.2.3. put on IUCD on 20 years
3.1.2.2.4. no contraception used since age 20
3.1.3. Drug history / allergy
3.1.4. Family history
3.1.5. Social / occupational history
3.1.5.1. husband
3.1.5.1.1. frequent drinker
3.1.5.1.2. smokes two packs a day
3.1.5.2. wife
3.1.5.2.1. was married at 24
3.1.5.2.2. she did not tell Raj about her previous pregnancy
3.1.5.2.3. now she is having very heavy periods and irregularity with big clots
3.1.5.2.4. having intercourse 3 times a week without discomfort but Raj seemed less keen
3.1.5.2.5. she was worried about her weight gain and facial hair
3.1.6. Systemic review
3.1.7. Physical examination
3.1.7.1. Husband
3.1.7.1.1. healthy male
3.1.7.1.2. obese 98 KG with normal secondary sexual characters
3.1.7.1.3. testicular volume is 18 ml both sides
3.1.7.1.4. vas present on both sides
3.1.7.1.5. chance of varicocele on left testis
3.1.7.1.6. rectal examination: normal prostate
3.1.7.2. wife
3.1.7.2.1. obese 89 kg
3.1.7.2.2. slight facial hair associated with her Mediterranean background
3.1.7.2.3. mild acne
3.1.7.2.4. vaginal examination
3.1.8. tests results
3.1.8.1. husband could not masturbate
3.1.8.1.1. 1.1 ml volume
3.1.8.1.2. 15% normal morphology
3.1.8.1.3. 5.4 million sperm/ml
3.1.8.1.4. 50% motility
3.1.8.1.5. previous sexual experience with a prostitute
3.1.8.2. wife
3.1.8.2.1. pap smear - neg
3.1.8.2.2. vaginal US
3.1.8.2.3. laparoscopy
3.1.8.2.4. free androgens 19.2