CIS – Communication test: H&P

TEMPLATE WHAT TO SAY & DO: CIS: (patient-Dr. interaction/rapport) – communication!

(1min blue sheet/mnemonics, name, VS (MENTALLY THINK “I AM DEALING with a REAL PERSON WITH
CC…”) [SMILE, LOOK CONFIDENT-friendly/ALPHA, MAKE PATIENT FEEL AT EASE/COMFORTABLE- EYE
CONTACT!!) - Polite, Calm, Comfortable

1. KNOCK KNOCK – enter smiling! = point

2. Mz/Mr (last name) Mr. Jones? – Hi, I am Dr. Le….I am the physician on call/duty today. Nice to
meet you – SMILE!! = point
a. Wash hands – I’ll be taking care of you today,
i. First I’ll ask you questions,
ii. then I’ll do a quick physical exam,
iii. then I’ll give you my impressions, - WILL THAT OKAY WITH YOU? (- asked
permission)

SIT DOWN on stool as say:

 Do you mind if I sit down and TAKE A FEW NOTES while we talk?
 May I have a seat & take some notes?
o I AM PERIODICALLY GOING TO BE TAKING NOTES, BUT THAT’S JUST
SO THAT I DON'T MISS ANY IMPORTANT INFO YOU GIVE ME.
PLEASE BE ASSURED- YOU HAVE MY UNDIVIDED ATTENTION"

3. Please tell me, how can I help you today/What brings you in today?
a. Pt: I have blood in my urine

4. I AM SO SORRY TO HEAR THAT (Genuine concern empathy – support emotions = point)

5. DRAPE & say CAN I MAKE YOU MORE COMFORTABLE?

a. Are you COMFORTABLE?
b. Are you comfortable sitting up or lying down?) = POINT

6. CAN YOU TELL ME more about (your/this….. (chief complaint)….

 when u decide the SP has said something u need to write ---

o tell him: "I AM PERIODICALLY GOING TO BE TAKING NOTES, BUT THAT IS
JUST SO THAT I DON'T MISS ANY IMPORTANT INFO YOU GIVE ME.
PLEASE BE ASSURED THAT U HAVE MY UNDIVIDED ATTENTION"

EMPATHY & Get back to focused history

 I understand this can be frustrating to you, but I want you know this will be a team effort
 Patient tells lengthy story irrelevant to CC, INTERRUPT POLITELY:
o “Excuse me, Mr. Johnson. I understand how important those issues are for you, but I’d
like to ask you some additional questions about your current problem.”

o “So as I understand it, your abdominal pains are infrequent, last a short time, and are
always in the middle of your belly. Now tell me about . . .”). – Summary, redirect convo.
Move to next step
 o You look sad; do you know the reason?” or
o “You look concerned; is there anything that is making you worry?.
 I UNDERSTAND THIS CAN BE FRUSTRATING TO YOU, BUT I WANT YOU KNOW
THIS WILL BE A TEAM EFFORT

TIPS:
 Pt coughs – ask about the cough
 Pt using TISSUE –
o ask to SEE IT & check SPUTUM COLOR (SPUTUM CULTURE & GRAM STAIN)
o Blood spot on tissue?

TRANSITION PHRASE: HPI to PMH

 “I need to ask you some questions about your health in the past,” or
 “I’d like to ask you a few questions about your lifestyle and personal habits.”

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Graded CHECK LIST on History - ASK PERTINENT QUESTIONS to CC!!
HISTORY TAKING - listen to Pt!, he’ll give you hint of what your next question will be
1. EYE CONTACT
2. Support Patient’s emotions
3. Create a relationship with Pt
4. Help Pt make decisions
a. Don’t interrupt pt while he’s speaking (will lose points)
b. Don’t leading questions
c. Don’t ask more than one question at a time
d. Don’t give FALSE assurance
e. Don’t be Judgemental

DO YOU HAVE ROS (diabetes?). Have you had_____ THEN FR CS PUBWAS-D B

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++

-Most of the Answers to my hx questions negative, unless one of two things:

1) It supports the Main Diagnoses.
2) It supports a Differential Diagnosis.

 LIQOR 3PAAA FDC AS

 THEN FOR CS; PUB SAWED

At end, before Physical Exam:

 “Is there anything you would like to add that I might have missed? "
o [they really do their best trying to remember if they can give you more
info. I asked this question 2-3 times with every patient., and most of
them added a few important points.]
o ask at the end of your history:
 Before PHYSICAL EXAM:
  “Is there anything else you forgot to tell me about?” or
 “Is there anything else you would like to tell me about?”

o DO you have anything you would like to add?

[I did run out of time in one elderly pt since her responses were slow, where i
missed the closure, summery and counseling, which I keep to the end]

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Then Physical exam

CHECK LIST – PHYSICAL EXAM

PHYSICAL EXAM
5. MAY I BEGIN the PHYSICAL EXAM?
6. WASH Hands – a little hand sanitizer “have you gone holiday shopping?”
7. DRAPE PATIENT
8. INFORM PT OF STEPS
9. WARM STETHASCOPE + USE DISPOSABLE TOOLS
10. EXAM Under the gown
11. Don’t repeat painful maneuvers
12. Don’t do Breast/Pelvic/Rectal/Genital exams

+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
DO FOCUSED PHYSICAL EXAM:
ENDING the PHYSICAL EXAM SAY:
(End the patient encounterone tends to forget and miss.) – THANK YOU
 “Ok Mr. J, (ALRIGHT,)
o Thank you for letting me examine you and answering all of my
questions. Before I tell you my IMPRESSION, I would like to ask
you a few more questions….
 What do you think is causing this?
 How is this affecting Your life? ((Impact on pt life –QUALITY of
life…..AFFECTS SLEEP or WORK?))

++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Wash hands
Drape waist down
May I begin the exam?
“If you don’t mind, I would like to perform a general inspection.” Oftentimes a bruise, a surgical scar, a
bandage, or asymmetry may be overlooked because the examiner is focusing on the tree rather than the
forest.

LOOK, Touch, Listen

Ex:
CVS: Inspect: skin color, cigarette stains, pulsations in the neck, the appearance of labored breathing,
and movement of the precordium.
  May I untie your gown here/to examine your chest?
 Can I move the sheet down to examine your belly?

Do an exam. “Thank you”

Crucial to keep the patient informed

VS: wnl
GE: (WD/WN, NAD, AOx3)
- Looks sad
SKIN: (warm, dry, intact)
HEENT: (NC/AT, PERRLA, EOM-I, no conjunctival pallor or injection, no scleral icterus)
(mouth and pharynx nl) MMM? Moist mucous membranes, no mucosal inflammation or pallor,
erythema or exudate
NECK: Supple, no masses, full ROM, no tracheal deviation, no JVD, no carotid bruit or
lymphadenopathy. nl thyroid
THROAT: MMM, MOUTH & PHARYNX NL
CHEST: (CTA b/l all lung fields)
CV: (RRR, nl s1, s2, no m/r/g)
ABD: (nl shape, soft, NT/ND, tympanic in all four quadrants. No masses on palpation. Nl pitch and
activity, no HSM)
MSK: no muscle atrophy, swelling, or tenderness
EXT: no clubbing, cyanosis, or edema
VASC: pulses carotid, radial, posterior tibial, dorsalis pedis b/l 2+
NEURO: (CN 2-12 grossly intact,
DTRs: 2+
-Babinski:
Gait: nl (shuffling, leans forward)
Cerebellum: no dysdiadochokinesia, no dysmetria

 I will need to do a Breast/Pelvic, Rectal, Genital exam later.

***(You may ask the patient any additional questions that you feel may be pertinent to the history. It is
recommended, however, that you pause the physical exam while communicating to reestablish eye
contact.)***

DON”T FORGET:
 Listening to the heart in a female patient: You can place the stethoscope anyWhere around the
patient’s bra and between the breasts. To auscultate or palpate the PMI, if necessary ask the
patient, “Can you please lift up your breast?”

SEVERE PAIN PATIENT: TO EXAMINE

 A patient in severe pain may initially seem unapproachable, refuse the physical exam, or insist
that you give him something to stop his pain. In such cases, you should first ask the patient’s
permission to perform the physical exam. If he refuses, gently say, “I understand that you are in
severe pain, and I want to help you. The physical exam that I want to do is very important in
helping determine what is causing your pain. I will be as quick and gentle as possible, and
once I find the reason for your pain, I should be able to give you something to make you more
comfortable.”
PATIENT WITH LESIONS
 If you see a scar, a mole (nevus), a psoriatic lesion, or any other skin lesion during the exam, you
should mention it and ask the patient about it even if it is not related to the patient’s complaint.

 Examining bruising: Inquire about any bruises you see on the patient’s body, and think about
abuse as a possible cause.

NEURO: Running out of time: If you don’t have time for a full mini-mental status exam, at least ask
patients if they know their name, where they are, and what day it is.

Fatigue:
 HEENT+thyroid CHECK,
 Lung listen, heart listen,
 ABD: ausc, percuss, palpate (+rebound & murphy’s sign)
 Ext: inspect, palp

Lung case:
 HEENT+ CHEST (full: TVF, palp, percuss) +CV – listen
 CXR: AP vs Lateral

Heart Case:
 Inspect, Palpate, Auscultate
 Cynaosis, No JVD, no Parasternal Heaves, No PALPABLE THRILLS, PMI

UTI OR PID OR PELVIC CASE:

 ABD, INGUINAL NODES

PSYCHIATRY CASE: SIG E CAPS

 Depressed mood?
 STRESS?

JOINT PAIN:
 Inspect, Palpate JOINT, ROM
 NEURO: all SENOSRY & DTRs

TIP: Great Question: (gotta do CV & CHEST every case?)
-Well here is where you have to balance things, because the truth is that nobody
knows if it is really required or not. So what I did was, if time allowed me, and I was
already examining the abdomen for example, I'd ask the pt to lift up his gown further
and do a quick Cardiac Auscultation. I did this for about 3-4 cases. .. BUT Don't make
my same mistake!, I forgot to Cover the Pt's abdomen while auscultating his
chest.

-When I got a respiratory Case > You have to include an HEENT examination.
-If it's a UTI or PID or any case where would you examine the pelvic region [not
allowed] > Just Examine the Abdomen. and Inguinal LNs [allowed].

IF LIVER DISEASE PATIENT

HEENT- add SCLERA NL
EXT- NO ASTEREXIS

IF EAR COMPLAINT OR DIZZINESS- HEENT- add TMs NL

CNS- add RINNE'S +VE(AC>BC) AND WEBER'S(NO LATERALIZATION)

///////////////////////////////////////////////////////////

DON’T forget WORKUP & COUNSELLING

1. Consent for HIV testing
2. GI case: do RECTAL EXAM
3. Male: genital exam
4. Female: Breast exam & pelvic exam