12-21-2004, 12:17 PM
TIPS:
. Don't forget to knock before entering the room.
. If the patient is not in terrible pain try to introduce yourself
with a handshake.
. Always keep eye contact
. be compassionate and PATIENT
. smile whenever appropriate and NEVER interrupt the patient or try to
hurry him!
. Never talk to the patient not facing him except the physical exam part.
. Wash your hands BEFORE the physical exam.
. Let the patient know whatever you are going to do in advance.
. NEVER ignore even the most ridiculous or simplest question or
concern raised by the
patient.
. Don't be afraid to talk about the weather or patient's wedding etc.
to make him relax.
Sometimes (especially with difficult patients) that's the point of
the encounter.
. Patient's modesty should always be your concern. Always cover parts
of the body
you're not examining. Explain why some maneuvers are necessary etc.
. Always help your patient and show concern about his safety and
comfort (leg support,
level of light in the room, helping him/her getting up etc.)
. Finally explain your findings and plan of action very shortly,
letting the patient know
that it's a pleasure and an honor helping him and you will be very
thorough in taking
care of him. If the patient doesn't have any questions say good bay
and once again
assure patient you will do whatever possible to help him without
giving false
reassurance.
GENERAL SCRIPT
Ms. X? Good morning.
My name is Dr. Y It's nice to meet you. I'll be taking care of you
today. I'd like to ask you few questions, so let's get started, OK?
CC:
Ms X, what made you want to see a doctor today?
HPI: (following questions are related to pain as a major complain. In
the case of other complains, modify the questions according to
symptoms. For example: in the case of diarrhea ask about sick
contacts, travel story etc.)
. Please show me exactly where the pain is.
. Does it ever move anywhere else?
. How would you describe the pain? (sharp, stabbing, vague, burning, dull, etc.)
. If 10 is the worst pain you've ever had, where is this pain on a
scale of 1 to 10?
. Have you ever had this before?
. When did it start?
. How often do you get it?
. Do you have idea of what might have brought this on?
. Has this pain changed any over time? How?
. Does anything make it worse?
. Does anything make it better?
. Do you have any other symptoms, like_____________? How
about_________? __________?
So, Ms X, Let me summarize what you've told me so far, OK?
________________________________________________________Is that right?
PMH:
OK Ms X, now I need to ask you some questions about your health in general.
. Have you ever had any serious illness?
. How about ________? _____________? _________________?
. Have you ever had any accidents or injuries?
. Have you ever had surgery?
. Have you ever had to stay in hospital otherwise?
. Are you allergic to anything? Drugs? Food? Anything else?
. Do you have any pets or plants?
. Ms Cooke, are you taking any prescribed medications?
. What? How much? For how long?
. Do you have it now? May I see it?
. How about OTC (over-the-counter) products?
. Have there been any recent changes in your urinary habits?
. Have you had any changes in your bowel habits lately?
. Has your weight changed recently?
. Have you noticed any changes in your sleeping pattern?
OB & GYN Hx:
Ms X, now I'd like to ask you some questions about your period cycle
and eventual pregnancies. Is it OK with you?
. At what age did you start your period?
. When was your last menstrual period (LMP)?
. Do you have your periods regularly (every month)?
. How many days is in your cycle?
. On a heavy day, how many pads or tampons do you use?
. Do you have any problems with PMS?
. Have you ever been pregnant?
. How many times?
. Do you have any children?
. Have you ever had a miscarriage?
. Can you tell me what happened with the pregnancy? In what trimester?
. Have you ever had an abortion?
Sexual Hx:
Ms X, now I need to ask you some important questions about your
personal habits in order to get a complete picture of your health.
Whatever you tell me will be kept confidential.
. Ms X, are you sexually active now?
. How many sexual partners do you currently have?
. Over the last year, how many sexual partners have you had?
. Are your sexual partners men, women or both?
. Do you use condoms? Always?
. Do you use any other contraceptives? What type?
. Have you ever had STD?
SH:
Ms X, now I'd like to ask you some questions about your work and social life.
. What type of work do you do?
. Is it stressful? How is your performance? Satisfaction?
. Are you exposed to ___________? (noise, pollutants, carcinogens, etc.)
It will be helpful for me to know something about your lifestyle.
. Do you smoke? (or use any kind of tobacco?)
. How many packs a day? For how long?
. Do you drink alcohol?
. How much? How often?
. Do you use any recreational drugs? Have you ever injected drugs?
OK Ms X, now please tell me about your home life.
. Are you married?
. With whom do you live?
. Do you feel safe at home?
. Do you have any support?
FH:
All right, now I' d like to find out about your family's health.
. Has anyone in your family ever had__________? How about_________? __________?
. Are your parents still living?
. What caused your mother/father death?
. Do you have any siblings? How are they?
Thank you for answering all those questions. Now I need to take a
physical exam so I'll just wash my hands. Excuse me.
OK Ms X, let me begin by________________
Al right Ms X, now I 'd like to sit down and talk over what I think so far.
First let me summarize. You told me that ___________________ and
_________________ and__________. On the physical exam I found
____________________________________.
I believe that this may involve your ______________________.
I'm considering a couple of possibilities. It may be
____________________, which is ___________ or ________________, which
is, or __________________________ possibly, which is _____________.
I need to run some tests in order to find out exactly what it is. I
need to have: ____________________.
As son as I study results, let's meet again to go over everything. At
that time I'll explain the details and we'll talk about your options
for treatment. (In the psychiatric case ask about counselor or the
support group)
Ms X, do you have any concerns or questions you'd like to ask?
Well, then I'm very grateful that I'll be able to work with you Ms X.
Thank you for coming in. I want to reassure you that I'll be very
careful and thorough in helping you.
Bye for now. Take care.
PSYCHIATRIC EXAMINATION
I would like to ask you some questions to see your orientation.
Can you tell your name and your age? (person orientation)
Do you know where are we now? (place orientation)
Do you know what the day is it today? (time orientation)
Now I would like to ask you some questions to see how your memory is.
I will name three objects to you and I want you to repeat them immediately, OK?
"Bed, pen and book" (rapid memory)
After the patient mentions the names, tell him "I will ask you to
repeat these names after few minutes."
Do you remember how was the weather yesterday? (recent memory)
Do you remember your birth date? (remote memory)
Now, can you repeat for me the names that I have just mentioned to
you? (short memory)
Ask the patient," Are you left handed or right handed?"?
I will give you a piece of paper. I want you to take the paper from my
hand, fold the paper in its half and put it on the floor (3-step
command)
I want you to draw a face of clock with its hands and make its hands
on 10 and 11"
Ask the patient, "I want you to subtract 7 from 100 serially..(CONCENTRATION)
Could you please tell me who were the first and the last president of
the US (fund knowledge)
Would you mind explaining this proverb for me (people who live in
glassy houses shouldn't throw stones) (ABSTRACT and REASONING)
What would you do if you see a fire coming out from a paper basket? (JUDGEMENT)
Do you think you need help? (insight)
DEMENTIA:
. Have you ever had any head trauma?
. Do you complain of any heart problems?
. Do you complain of high blood pressure or DM?
. Do you have any problems of remembering things?
. Do you have any problems in performing your daily activities like shopping or
transferring?
. Do you have any problems in using instruments in your life like cooking or
telephoning?
. Do you have any feelings of depression, hopelessness or worthlessness?
DEPRESSION: (SIGN E CAPS)
. Do you have difficulty in falling asleep or in maintaining your sleep?
. Do you feel that you have you're your interest in the surroundings,
in your social
relationships?
. Do you have the feeling of guilt or blame?
. Do you feel fatigue or weak?
. Do you feel that you have lost your concentration while doing things?
. Do you have any weight or appetite changes?
. Have you ever tried to kill yourself?
. Did you have any suicidal attempts in the pasts?
. Do you have any suicidal plans in the future?
. Do you have any changes in your bowel movements?
. Do you feel that you like to be in warm places and you no longer
tolerate the cold
places?
. Did you notice any changes in your skin, hair?
. Have you recently noticed any changes in your voice (hoarseness, lowering)
PTSD:
. Do you have sleeping disorders?
. Do you have any nightmares?
. Have you had any recent traumatic event?
ANXIETY/PANIC DISORDERS:
. Do you have fright feelings?
. Is there anything that makes you feel afraid or frightened?
. Do you have episodes of shortness of breath and sweating?
PSYCHOSIS:
. Do people ever say they think you're hearing or seeing things that
others don't?
. Do people ever say they think you have extremely unrealistic ideas
about yourself or about life in general?
WILLINGNESS TO SEEK HELP
. A good counselor can help you through this difficult time. Would you
like a list of professionals in the local area?
. I just want you to know that you're not alone. There are people in a
situation similar to yours. There are some good support groups in the
community. Would you like to have this kind of peer support?
. Don't forget to knock before entering the room.
. If the patient is not in terrible pain try to introduce yourself
with a handshake.
. Always keep eye contact
. be compassionate and PATIENT
. smile whenever appropriate and NEVER interrupt the patient or try to
hurry him!
. Never talk to the patient not facing him except the physical exam part.
. Wash your hands BEFORE the physical exam.
. Let the patient know whatever you are going to do in advance.
. NEVER ignore even the most ridiculous or simplest question or
concern raised by the
patient.
. Don't be afraid to talk about the weather or patient's wedding etc.
to make him relax.
Sometimes (especially with difficult patients) that's the point of
the encounter.
. Patient's modesty should always be your concern. Always cover parts
of the body
you're not examining. Explain why some maneuvers are necessary etc.
. Always help your patient and show concern about his safety and
comfort (leg support,
level of light in the room, helping him/her getting up etc.)
. Finally explain your findings and plan of action very shortly,
letting the patient know
that it's a pleasure and an honor helping him and you will be very
thorough in taking
care of him. If the patient doesn't have any questions say good bay
and once again
assure patient you will do whatever possible to help him without
giving false
reassurance.
GENERAL SCRIPT
Ms. X? Good morning.
My name is Dr. Y It's nice to meet you. I'll be taking care of you
today. I'd like to ask you few questions, so let's get started, OK?
CC:
Ms X, what made you want to see a doctor today?
HPI: (following questions are related to pain as a major complain. In
the case of other complains, modify the questions according to
symptoms. For example: in the case of diarrhea ask about sick
contacts, travel story etc.)
. Please show me exactly where the pain is.
. Does it ever move anywhere else?
. How would you describe the pain? (sharp, stabbing, vague, burning, dull, etc.)
. If 10 is the worst pain you've ever had, where is this pain on a
scale of 1 to 10?
. Have you ever had this before?
. When did it start?
. How often do you get it?
. Do you have idea of what might have brought this on?
. Has this pain changed any over time? How?
. Does anything make it worse?
. Does anything make it better?
. Do you have any other symptoms, like_____________? How
about_________? __________?
So, Ms X, Let me summarize what you've told me so far, OK?
________________________________________________________Is that right?
PMH:
OK Ms X, now I need to ask you some questions about your health in general.
. Have you ever had any serious illness?
. How about ________? _____________? _________________?
. Have you ever had any accidents or injuries?
. Have you ever had surgery?
. Have you ever had to stay in hospital otherwise?
. Are you allergic to anything? Drugs? Food? Anything else?
. Do you have any pets or plants?
. Ms Cooke, are you taking any prescribed medications?
. What? How much? For how long?
. Do you have it now? May I see it?
. How about OTC (over-the-counter) products?
. Have there been any recent changes in your urinary habits?
. Have you had any changes in your bowel habits lately?
. Has your weight changed recently?
. Have you noticed any changes in your sleeping pattern?
OB & GYN Hx:
Ms X, now I'd like to ask you some questions about your period cycle
and eventual pregnancies. Is it OK with you?
. At what age did you start your period?
. When was your last menstrual period (LMP)?
. Do you have your periods regularly (every month)?
. How many days is in your cycle?
. On a heavy day, how many pads or tampons do you use?
. Do you have any problems with PMS?
. Have you ever been pregnant?
. How many times?
. Do you have any children?
. Have you ever had a miscarriage?
. Can you tell me what happened with the pregnancy? In what trimester?
. Have you ever had an abortion?
Sexual Hx:
Ms X, now I need to ask you some important questions about your
personal habits in order to get a complete picture of your health.
Whatever you tell me will be kept confidential.
. Ms X, are you sexually active now?
. How many sexual partners do you currently have?
. Over the last year, how many sexual partners have you had?
. Are your sexual partners men, women or both?
. Do you use condoms? Always?
. Do you use any other contraceptives? What type?
. Have you ever had STD?
SH:
Ms X, now I'd like to ask you some questions about your work and social life.
. What type of work do you do?
. Is it stressful? How is your performance? Satisfaction?
. Are you exposed to ___________? (noise, pollutants, carcinogens, etc.)
It will be helpful for me to know something about your lifestyle.
. Do you smoke? (or use any kind of tobacco?)
. How many packs a day? For how long?
. Do you drink alcohol?
. How much? How often?
. Do you use any recreational drugs? Have you ever injected drugs?
OK Ms X, now please tell me about your home life.
. Are you married?
. With whom do you live?
. Do you feel safe at home?
. Do you have any support?
FH:
All right, now I' d like to find out about your family's health.
. Has anyone in your family ever had__________? How about_________? __________?
. Are your parents still living?
. What caused your mother/father death?
. Do you have any siblings? How are they?
Thank you for answering all those questions. Now I need to take a
physical exam so I'll just wash my hands. Excuse me.
OK Ms X, let me begin by________________
Al right Ms X, now I 'd like to sit down and talk over what I think so far.
First let me summarize. You told me that ___________________ and
_________________ and__________. On the physical exam I found
____________________________________.
I believe that this may involve your ______________________.
I'm considering a couple of possibilities. It may be
____________________, which is ___________ or ________________, which
is, or __________________________ possibly, which is _____________.
I need to run some tests in order to find out exactly what it is. I
need to have: ____________________.
As son as I study results, let's meet again to go over everything. At
that time I'll explain the details and we'll talk about your options
for treatment. (In the psychiatric case ask about counselor or the
support group)
Ms X, do you have any concerns or questions you'd like to ask?
Well, then I'm very grateful that I'll be able to work with you Ms X.
Thank you for coming in. I want to reassure you that I'll be very
careful and thorough in helping you.
Bye for now. Take care.
PSYCHIATRIC EXAMINATION
I would like to ask you some questions to see your orientation.
Can you tell your name and your age? (person orientation)
Do you know where are we now? (place orientation)
Do you know what the day is it today? (time orientation)
Now I would like to ask you some questions to see how your memory is.
I will name three objects to you and I want you to repeat them immediately, OK?
"Bed, pen and book" (rapid memory)
After the patient mentions the names, tell him "I will ask you to
repeat these names after few minutes."
Do you remember how was the weather yesterday? (recent memory)
Do you remember your birth date? (remote memory)
Now, can you repeat for me the names that I have just mentioned to
you? (short memory)
Ask the patient," Are you left handed or right handed?"?
I will give you a piece of paper. I want you to take the paper from my
hand, fold the paper in its half and put it on the floor (3-step
command)
I want you to draw a face of clock with its hands and make its hands
on 10 and 11"
Ask the patient, "I want you to subtract 7 from 100 serially..(CONCENTRATION)
Could you please tell me who were the first and the last president of
the US (fund knowledge)
Would you mind explaining this proverb for me (people who live in
glassy houses shouldn't throw stones) (ABSTRACT and REASONING)
What would you do if you see a fire coming out from a paper basket? (JUDGEMENT)
Do you think you need help? (insight)
DEMENTIA:
. Have you ever had any head trauma?
. Do you complain of any heart problems?
. Do you complain of high blood pressure or DM?
. Do you have any problems of remembering things?
. Do you have any problems in performing your daily activities like shopping or
transferring?
. Do you have any problems in using instruments in your life like cooking or
telephoning?
. Do you have any feelings of depression, hopelessness or worthlessness?
DEPRESSION: (SIGN E CAPS)
. Do you have difficulty in falling asleep or in maintaining your sleep?
. Do you feel that you have you're your interest in the surroundings,
in your social
relationships?
. Do you have the feeling of guilt or blame?
. Do you feel fatigue or weak?
. Do you feel that you have lost your concentration while doing things?
. Do you have any weight or appetite changes?
. Have you ever tried to kill yourself?
. Did you have any suicidal attempts in the pasts?
. Do you have any suicidal plans in the future?
. Do you have any changes in your bowel movements?
. Do you feel that you like to be in warm places and you no longer
tolerate the cold
places?
. Did you notice any changes in your skin, hair?
. Have you recently noticed any changes in your voice (hoarseness, lowering)
PTSD:
. Do you have sleeping disorders?
. Do you have any nightmares?
. Have you had any recent traumatic event?
ANXIETY/PANIC DISORDERS:
. Do you have fright feelings?
. Is there anything that makes you feel afraid or frightened?
. Do you have episodes of shortness of breath and sweating?
PSYCHOSIS:
. Do people ever say they think you're hearing or seeing things that
others don't?
. Do people ever say they think you have extremely unrealistic ideas
about yourself or about life in general?
WILLINGNESS TO SEEK HELP
. A good counselor can help you through this difficult time. Would you
like a list of professionals in the local area?
. I just want you to know that you're not alone. There are people in a
situation similar to yours. There are some good support groups in the
community. Would you like to have this kind of peer support?