INTRODUCTION
Hello, I’m Dr. Kim. --? (How can I pronounce your name?)
It's nice to meet you. I am the physician in this hospital, and I'm going to be asking you
some questions and examining you.
Is that OK with you?
(Is this your most comfortable position?)
Everything we talk about today will be kept confidential.
May I have a seat?
HISTORY TAKING (OPCSDF LIQR/ABCCCO SAAA)
How can I help you today?
Onset: When did it start first?
Progression: Is it staying the same or getting better or worse?
Constant: Is it constant or does it come and go?
Setting: What were you doing when you had the symptom for the first time?
Duration: How long does it last?
Frequency: How many times a day are you having the symptom?
Location: Can you point to exactly where your neck pain hurts?
Intensity: On a scale from 1 to 10, with 10 being the worst pain you have ever had,
which number would you rate the pain?
Quality: Could you describe the pain?
Radiation: Does the pain move anywhere?
Do you bring up any mucus?
Amount: How much mucus did you get?
Blood: Did you see any blood in it?
Constancy: Is it constant or does it come and go?
Color: What color was it?
Context: How would you describe your mucus?
Odor: How does it smell?
Similar episode before: Have you had any similar problem before?
Alleviating factors: Does anything make your symptoms better? What makes it better?
Aggravating factors: Does anything make your symptoms worse? What makes it worse?
Associated symptoms(ROS): I want to ask you about other symptoms that you may be
having.
SOCIAL HISTORY (PAMFO SSADO)
Okay, --. Now, I'm going to ask you some questions about your health in general.
Past medical: Do you have any major illnesses?
Surgery history: Have you had any surgeries before?
Allergy: Do you have any allergies? What reaction did you get?
Medication: Are you taking any medications? Over-the-counter drugs?
I’m going to ask something about your family.
Family history: Now, I would like to ask you about your family's medical conditions.
Does anyone in your family have any major illnesses?
I'm going to be asking you about social habit. Everything we talk today will be kept
confidential.
Smoke: Do you smoke? How many packs a day? How long have you smoked?
Alcohol: Do you drink alcohol? What do you drink? How much? How long?
-How many times in the past year have you had 5/4 or more drinks in a day?
Drug: Do you use any recreational drugs such as marijuana or cocaine?
Occupation: What do you do for your living?
OB/GYN HISTORY
I’m going to ask you about female health.
LMP: When was your last menstrual period?
-Lactation: Have you had any discharge from the nipples?
-Menarche: How old were you when you had your first period?
Period duration: How many days does your period last?
Regularity: Are your periods regular?
Tampons or pads per day: How many pads or tampons do you use each day and on the
heaviest day of your periods?
-Vaginal discharge: Have you had any vaginal discharge?
-Vaginal dryness: Do you have any vaginal dryness?
-Vaginal pruritus: Have you had any itching in the vaginal area?
Contraceptive use: Are you on any birth control pills?
-Cramps with period: Have you had any cramps with period?
-Spotting: Do you bleed in between your periods?
-Postcoital bleeding: Did you ever notice any bleeding after intercourse?
Pregnancy (Gravida/ Para): Have you ever been pregnant? Is there any possibility you
may be pregnant?
-Abortion/ Miscarriage: Have you ever had a miscarriage or abortion?
-Pap smear: Have you had a Pap smear before?
STD history: Have you ever had a sexually transmitted disease?
SEXUAL HISTORY
Okay, --. Now I would like to ask a few questions about your sexual history. Plz
understand that it will be kept confidential between you and me. Try to be as honest as
possible. Is that okay with you?
Activeness: Are you sexually active?
Partners: How many partners do you have now?
(How many partners have you had before?)
Sex: Are you active with male, female, or both?
Contraception: Do you use any contraceptives? What do you use? Do you use it
regularly?
STD risk: Have you ever had a sexually transmitted disease?
SUMMARIZE
Let me summarize your problem. You were well until---. Would you like to add
something or correct something?
PHYSICAL EXAMS
Thank you for answering my questions. Now I need to examine you. Before I begin, let
me sanitize my hands.
Okay, ---. Now, I would like to do a physical examination on you. Can you untie and
lift your gown?
I'm going to tie up your gown.
-Rules of PE-GEN x5 (eyes, mouth, neck=A+LN, radial pulses, pedal edema)
-MAIN system x4
-EXTRA-system x2
GENERAL: No pallor/icterus/cyanosis/rashes/clubbing/pedal edema. Mucosa=pink +
moist
HEENT:
-Inspection: I am looking at your head.
-Now, I'm going to check your eyes. Please look up for me. Look down for me.
-Can you plz open your mouth? I need to check the inside of your mouth and your
throat.
(conjunctival pallor, NCAT, MMM, OP cl)
Neck:
-I would check for swollen glands. Let me press on this area.
-Let me check your thyroid. Could you plz swallow saliva?
(supple, no LAD, no thyromegaly)
CV: Inspection, palpation, and auscultation x4, (plus JVD)
-Okay, ---, now I would like to examine your heart. Now, I would like to listen to your
heart.
(RRR, pmi = undisplaced, nl S1/S2, no r/g/m)
Chest: Inspection, palpation (tenderness + TVF), percussion, and auscultation
(no scars /bruises /deformities, no tenderness, TVF=NL, resonant b/l, CTA B/L)
Abd: Inspection, auscultation, palpation(light→deep), percussion, Murphy
(no scars, hernias, makeup, +BSx4Qs, soft, non-distend, non-tenderness, no
organomegaly)
-Can you please lie down? Let me help you, and pull up the leg rest. Are you
comfortable now?
Ext(Calf): Inspection, palpation, and Homan’s sign
Neuro: A and O x3, cranial 2-12 grossly intact, strength MMT5/5 throughout, DTRs
symmetric 2+ in all exts, sensory decreased pinprick and vibration sense on lt arm,
Romberg neg,
Thank you for answering my questions.
On the basis of information which I gathered from your history and physical exam, your
symptoms might be explained by -, which is-. To make final diagnosis and rule out
other possibilities, we need to run some tests. I will order - to see if -. As soon as I get
the results, we can meet again to go over everything.
Do you understand what I said? (Are you following what I said)? Does this sound OK?
Do you have any questions or concerns you would like to ask before I go?
I will call you later today when the results are back. Thanks for your cooperation.
Thank you. I want to be sure I understand this correctly. We may need to see child for
PE or to do some tests. I will find out what is his matter and get your child treatment.
Do you have any questions? Thank you for your time.
Patient note
Order tests= faster, cheaper, and easier
PE findings= CC, abnormal VS, GA, abnormal PE findings
HEENT
Head, Eyes
-headache (aura)
-vision change
-dizziness
-LOC/ seizure
-nausea/ vomit
-light sensitivity of eyes
Ear
-ear pain/ pressure
-ear discharge
Nose
-runny nose
-sneezing
-facial pain
Throat
-sore throat
-diff w/ swallowing
-drooling of saliva
LUNG-5
-cough (sputum, phlegm)
-fever
-sick contact
-noisy breathing
-cyanosis “Have you noticed blue discoloration of your skin?”
HEART-9
-chest pain
-palpitation
-excessive sweat
-nausea/vomiting
-dizziness
-anxiety
-swelling your feet
-orthopnea ‘Can you lie flat?’
-sob while walking
ABDOMEN-9
Have you been more thirsty than usual?
Do you feel nauseated?
Do you feel sick to your stomach?
Have you had any pain after eating meals or at night?
Did/Do you vomit/throw up?
Have you had any constipation or diarrhea?
How many bowel movements do you have per week?
Have you had yellow eyes or skin?
Have you recently taken any antibiotics?
NEURO
-numbness/ tingling/ weakness
-diff w/ walking/ talking/ swallowing
-diff w/ controlling urination
-specific time or day
DVT-2
-pain in the calf
-Travel: Have you recently traveled? How did you get there? How long was the
journey?
GERD-2
-heart burn
-Do you bring up any liquid back into your mouth?
CANCER-6
-fever
-night sweats
-lumps or bumps
-energy level (use “how” question)
-BW changes recently
-appetite
ANEMIA-5
-dizziness
-SOB
-palpitation
-bloody stools
-black stools
WADESS JT
-weight
-appetite
-diet
-exercise
-sleep
-job
-travel
Qs for DM refill
= 5 basic Qs + 5 monitor Qs + 3 side effect Qs
5 basic Qs
-when
-type
-symptoms
-treatment
1.
diet
2.
exercise
3.
medication (name, dose, site, compliance)
5 monitor Qs
-BG (home monitoring, freq of monitoring, last reading -what and when/ fast or after
meal)
-HbA1C (checking HbA1C, last reading –what and when)
-DM Dr visit (when and what the doctor said)
-Eye Dr visit (when and what the doctor said)
-Feet check (check +/-, ulcers or any skin changes)
3 side effect Qs
-acute=belly pain
-chronic=eye, numbness, polyuria, polydipsia, polyphagia
-meds=dizziness
PE=eye, heart, feet
VOICE
-voice quality
-voice abuse (sing or shout a lot)
HYPOTHYROIDISM
-skin change (dry skin, dry hair)
-cold intolerance
-constipation
-weight gain
-lumps on neck
-neck pain
LOC
-eye witness (who and what)
-jerky movement (how long, how do you feel after regain consciousness, bite tongue, leak
urine/ stool)
-skip meals before the episode
-drink enough fluid, play under the sun for long hours
PATIENT NOTE
No pallor/icterus/cyanosis/rashes/clubbing/pedal edema. Mucosa=pink+moist
HEENT=NC/AT, teeth and gums are healthy, no pallor/ no throat or nasal congestion/ no
sinus tenderness/ nasal discharge, no neck LAD
CV: RRR,pmi=undisplaced, nl S1/S2, no r/g/m
Chest: no scars/ bruises/ deformities, no tenderness, TVF=NL, resonant b/l, CTA B/L
Abd: no scar/ bruises/ visible lumps, BS+, soft and flat, RUQ tenderness, no HSM,
resonant all 4Q, Murphy sign+
Neuro: AO x 2(DISORIENTED TO TIME)
3 words recall=3/3, can't spell backwards, cranial nerve 2 -12 intact
power=5/5 b/l upper limb + lower limb, sensation intact to dull touch, DTR 2+ (knees)
Babinski downward b/l, ROMBERG+, GAIT=NL
Feet exam=no scars/ deformities/ ulcers, redness, no warmth, no tender, DP 2+ b/l,
sensation impaired to soft touch b/l feet, power 5/5 b/l LE, ankle jerks 2+ b/l, vibration
impaired both feet.