Screen_Recording_20250311_150144_Teams

Introduction to Patient Encounter

• Importance of Communication with Receptionists

  • Use simple language when communicating symptoms to non-medical personnel.

  • Avoid medical jargon; stay concise (e.g. "explosive diarrhea" instead of detailed medical terms).

Chief Complaint List

• Maintaining a concise list of patient grievances is essential.

• Example of a chief complaint list:

  • Cut hand

  • Follow-up foot

  • Weight loss

  • Scratching arms

  • Hit right eye

  • Diarrhea

  • Left pinky pain

  • Nausea

  • Follow-up cuts and laceration

  • Right ankle

  • Dry hands

  • Sore in mouth

• Purpose of the list: prioritize daily patient visits based on urgency.

Evaluating Urgency

• Immediate assessment of critical cases:

  • Chest pain, eye injury, signs of severe bleeding - may require ER visit.

  • Determine if the complaint is something manageable or requires specialist attention (e.g. oncology, urology).

History of Present Illness (HPI)

• Frame and structure for patient stories in HPI:

  • Start with follow-up on any new changes since the last visit.

  • Take note of any new diagnoses or surgeries since the last visit, which can save time and inform treatment.

• Importance of asking about medication changes that may affect current symptoms.

Old CARTS** Mnemonic for Symptom Evaluation

• Onset: When did the symptoms start?

• Location: Where is the problem?

• Duration: How long have the symptoms lasted?

• Character: Describe the nature of the pain (sharp, dull, etc.).

• Aggravating factors: What makes it worse?

• Relieving factors: What helps alleviate the symptoms?

• Treatment: Previous treatments attempted?

• Severity: Scale of pain or severity from 1-10.

Past Medical History (PMH)

• Verify if conditions were diagnosed by a medical provider.

• Check for discrepancies with current medications and treatments.

• Investigate any surgeries that could relate to the current visit.

Medication and Allergies

• Distinguish between true allergies and drug intolerances.

  • Allergies result in physical reactions (e.g. hives, vomit).

  • Intolerances can result in discomfort but are not true allergic responses (e.g. diuretics causing frequent urination).

• Patients may encounter side effects of prescribed medications that warrant adjustments.

Family History

• Collect genetic information:

  • Inquire about living relatives and their health issues (heart disease, diabetes etc.)

  • Ask about causes of death for valuable hereditary insights.

Social History

• Understanding patient’s lifestyle: Job, marital status, sexual practices, substance use (alcohol, drugs, tobacco) can inform overall health.

• Queries about sexual history should be direct, avoiding judgments.

  • Important for understanding potential exposures to STIs or other health concerns.

Review of Systems

• Conduct a comprehensive review (12 or 14 system template) to ensure all relevant systems are covered.

• Need to ensure findings correlate with the chief complaint to maintain relevance in assessment and plan.

Physical Exam Documentation

• Document findings accurately corresponding to the physical examination.

  • Use quantifiable terms (strength comparisons, movements)

  • Avoid vague language and general observations in charts.

Assessment and Plan (SOAP Note)

Differential Diagnosis:

• Clearly define differential diagnoses based on symptoms and physical findings.

Treatment Plan:

• Include specifics on medications, treatments, and follow-up protocols.

  • Specify dosage, duration, and use clear instructions on next steps.

• Document patient education regarding treatments and methods to manage conditions.

Follow-Up Care

• Emphasize importance of monitoring patient’s progress through regular follow-ups.

• Instructions should include signs to watch for that may require immediate attention.

• Maintain comprehensive record keeping to ensure continuity of care and legal protection.