“ Hello Mr/Mrs… My name is….This is a very important exam for me. I will need to ask you a lot of questions very quickly. From time to time I may need to cut you off.
Please don’t feel that I’m being rude, it’s just that I need to get a lot of information very quickly.
How old are you? Are you allergic to anything? What are your health problems, I need to make a quick list (also quickly look at the drug chart).”
What do you see as the main issue with your health at the moment?
Past Medical History
“Mr.___ is a___year old (Heavy smoker) who presents with the diagnostic problem of ___ with the management problem of ___ on a background of ___”
What is the Patient’s Main problem?
Presentation (In great detail including systems review)
- How, when patient presented?
- Major events in disease course.
- Last major flare
- Location, radiation, quality, quantity, duration, frequency, aggravating and relieving factors, associated symptoms.
- For Pain use “SOCRATES”
Risk factors and Precipitants
- What Ix and their results. Any Ix missing?
Management (past, present, future)
- What was the initial treatment and side effect.
- When did they stop working and why?
- Complications of treatment
- If compliance poor, why?
- What treatment currently receiving?
- How do they monitor their treatment?
- Next set of treatment?
Prognosis and Insight.
What are your health problems?
Is this an active or inactive problem at present?
Current status –stable or not.
Social and Family History
List of medications with dose and frequency.
(group according to indications)
Is there a medication that is not on the list that should be there?
Allergies vs Adverse effects
Special questioning about insulin and warfarin.
Ask about compliance. If not, why?
Use of over the counter drugs and herbal meds.
Family history (Only the ones that are transmissible or increases risk)
Independence (Level of function)
Support- health of main caregiver. How well they are coping?
Devices and attachments
Gait-walk, squat down, stand up.
Ask for urinalysis, PR exam, tem chart.
Include relevant negatives.
“ On examination, Mr___ was alert and cooperative. He appeared comfortable at rest. His pulse, BP(lying/standing), RR was___
(Main system first) “CRG-NHEMS”
Cardiovascular examination showed___
(Be concise and precise)
Differential diagnosis and Investigations
Is this a predominantly Diagnostic or Management problem or both?
“ IN SUMMARY,
Mr.___ who is a ___ year old ___ who presents with major problem of ___. He also has ___ as well as multiple social concerns.
Currently his main problem is___”
The RULE of 3’s
What the PATIENT identifies as the main issue.
What YOU identify as the bigger priority.
Choose a chronic problem that needs on going management (pick the most obvious ie: diabetes, renal failure, etc)
Not more than 5 problems.
Social issues could be one of them.
For each Diagnostic problem, give 3 differentials.
Before ending the interview, ask the patient…
Is there anything else you want to tell me or you think I should know?
Is there anything else that the examiners were interested in?