Irfanmir 15 Minutes Conversation Notes (Usmle Step 2cs)

KICK THE BOARDS USMLE STEP 2 CS

15 MINUTES CONVERSATION NOTES

Prepared by Dr. Irfan Mir

KICK THE BOARDS. USMLE STEP 2 CS.

IRFANMIR “15 MINUTES CONVERSATION” NOTES

 Knock the door. > (First do Identification by saying) Mr John Smith ?

( > = wait for an ans then go for next Q )

 Hello Mr Smith My name is Dr Mir, your attending physician, How may I help You today ? here Pt will tell you CC;

> Say; sorry to hear that. (show sympathy and concern in your posture)

O (onset) ------------ How long you are having this problem ? > Plz tell me more about it ? > How did it start ? L (location) -------- Could you plz point it with one finger where exactly do u feel it ? D (duration) -------- How long does it last ? F (frequency) ------- How frequent it occurs? (Constant vs. Intermittent) P (progression) ---- Is it Progressive ? (getting Better or Worst or Same) Q (quality) ---------- Can u describe the pain how is it like ? I (intensity) --------- On the scale of 1/10 where 10 is the worst how do you grade your pain ? R (radiation) ------- Does it travel to some other part of the body ? All/Exa F ------------ What makes it better ? > What makes it worst ?  (Must sympathize at this point by saying) That must be very agonizing & distressful for you, > How do you feel abt ur condition ?  (must sympathize here again by saying) I understand that must be very unpleasant experience for you.  Are your Sxs causing any interference in ADL ? (Must do Counseling such as offering education and nursing help)  Where exactly do you need help (such as bathing/ cooking/ med/ grocery/ managing accounts/ coming out of bed etc)  I need to ask you some Qs about your health in general, is that OK ? (This ROS takes < 2 mins or even less if u practices more) (Go like that. Do u have fever, (wait for ans) chill (wait for ans), any sweating (wait for ans), dryness (carry on with the list below). (Do not say whole sentence again and again, just one Sx or organ is enough, as explained in above line) Asso Sxs ------- Fever/ chill/, sweating/ dryness, N/V, HA, Vision problem, Hearing problem, unusual smell, dizziness/ Loss of balance/ pass out / Involunteer muscle movement. Difficulty swallowing, Change in voice/ heart burn, Appetite /wt change, mass/lump any where in body, Rash/ skin Discoloration, SOB/ Palpitation, Nipple discharge, abd discomfort, bowel problem, urinary problem, Past similar sxs. Recent illness/ travel/ trauma/ bug bite/ new pet. Muscle pain, Bone /joint pain. Mood (sad happy), energy, Recent incident / accident in life, Impact of illness in life. Sleep. Denial ------- (What ever Pt denies while asking Associated Sxs write down under "denies" in ur pt notes) (On blue sheet write down only + ve findings; do not write - ve findings on blue sheet otherwise u will never be able to close the case)  I need to ask you some Qs abut your obstetric & gynecologic health, is that ok ? (Ask all following Qs if Case demands it, otherwise asking only 1st Q of each of the following line is enough) Obgyn --  When did you have ur first menstruation? > Was it reg? > How long was the cycle ? > How was the flow (low/med/heavy)  When was ur First day of LMP ? How long is the cycle now ? > How was the flow ? > Any cramps ? > # of tampons ?  Any intermittent bleeding ? > Any vaginal discharge ? > Pain During Sexual relationship ?  How many kids do you have ? > With natural delivery or C section ? > Any complication during pregnancy or after ?  Any Abortions ? > How many ? > In which trimester ? > Did you any received D&C ?  When did you have ur last Mammogram ? > and Pap smear ? how was the results ? (must do counseling for both if - ve)  Is there any bleeding problem in family or relatives ? (ask this Q in pt with menorrhagia. very imp) Medi/ All -- Are you taking any medication ? > Any herbal products ? > Do you have any allergies ? PMH ---  Do u have any other health issues (co morbidities)? > Have you ever been hospitalized for any reason ? > Any Accidents ? FH -----  Tell me about the health of ur parents ? (If parents are deceased say sorry to hear that & ask what was the cause of death)  Is there any health problem in Family or relatives such as mental illness > Cancer > bleeding problem ? SH -----  What do you do for living ? > any stress at job ?  (must ask support system) Is ur family supportive ? > Any problem there? > How about friends (r they supportive)?  Are you married ? > any problem there ? > How many Childrens ? > Any problem there ?  Do you drink Alcohol (EtOH) ? > what do you drink ? > How much ? > How Often ?

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KICK THE BOARDS. USMLE STEP 2 CS.

IRFANMIR “15 MINUTES CONVERSATION” NOTES

 Must ask CAGE? (must do counseling if + ve. See examples in counselling section) C = have u ever felt the need of CUT down on ur drinking? A= have u ever felt ANNOYED by criticism of ur drinking? G = Have u ever had GUILTY feeling about ur drinking? E = Have u ever had to drink first in morning as an EYE opener? (to get rid of hang over)  Do you smoke ? > How many PPD ? > From how many yrs ? (must do counseling if + ve)  Do you use any illicit drugs ? > What kind ? > How do you use it ? (must do counseling if + ve)  Do you use caffeinated drink or energy shots ? (must do counseling if + ve)  How is ur diet (healthy or fast food) ? > Do you exercise (type?) (must do counselling for healthy food / fiber/ exercise) * I need to ask you some Qs about your sexual heath & practices is that Ok ? > Here I also wants to reassure you that every thing we talk here will be confidential by all mean, is that Ok ? (must say that to express ur sense of pts confidentiality) SxH ---------  Are you sexually active ? > with whom ? (ask how many boyfriends did u have in past 1 yr sp if pt is unmarried ?)  How is your sexual interest (libido) ?  do you use contraception ? > Which method ?  Have you ever been diagnosed with STD ?  Have you every been tested for HIV ? (do counseling in needed) Phy Exam --  Now I need to perform a physical exam (PE) on you for which I have to untie your gown, Is that OK ?  I’ll try my best to minimize any discomfort or pain associated with PE. OK? (Must Drape the pt before u examine)  (while wearing gloves must say) Here I also like to assure u that u r in good hands & I will do my level best to help u ?  Explain every step as u perform exam (just like running commentary and keep doing it, do not stop at any time)  (upon finishing the examination must say) Thanks for letting me examine u. (Phys Exam should not exceeds 3 min) CLOSING --- (Must reserve 4 - 5 mins for closing)  Mr. Smith you said that you are having so & so problem + brief imp Sxs is that correct (wait for ans); OK  Well Mr. Brown at this point according to the information that u have provided me & physical examination findings my impression is that you are most likely having so & so problem (explain all terms) but very same Sxs can also be caused by some other potential reasons (explain two other causes). In order to get to the right dx I am indicating some routine test such as (tell few of the following) CBC ---- which is blood count and chemistry. Preg test -- to make sure that in case ur pregnant unknowingly, than we r avoiding medications that can cause harms to baby. U/A & Culture --- to rule out any infection / kidney problem. Sputum culture ---- In which we find the bacterial type. Fecal Occult Blood test ---- Which shows presence of blood in stool  As well as I want you to have some procedures such as ECG --- which is a Graphic cardiac reading that gives information about hearts health. Echocardiography --- which is the heart sonography Stress test --- they will put u on treadmill with different stress level to evaluate ur hearts health. Ultrasound (USG) --- which use sound waves to take pictures inside your body. Xrays / CT scan / MRI --- which is modern way to take images of the inside of your body. Endoscopy --- which is modern way to take pictures by mean of camera. Joint Aspiration ---- which is achieved by needle insertion and drawing out the fluid for examination. OR FNA Snellens Chart (visual acuity) Audiometry / Tympanometry PFT / Spirometry ABG / Pulse Oximetry Renal Functional test Pelvic exam, Rectal exam. etc

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KICK THE BOARDS. USMLE STEP 2 CS.

IRFANMIR “15 MINUTES CONVERSATION” NOTES

 As soon as test results come in I would like to sit with you to discuss all the tx option available.  Is there any thing you feel we need to discuss that we haven’t talked about ?  Do you have any Q ? (this is one of the possibility, for that concern I have indicated a test to make sure we r not missing any thing).  Is that Answer ur Q? > Do you have any other Q ?  If you remember any Q later please feel free to call my office I will be glad to answer you.  And for the time being until results are available I will recommend that keep taking ur Medication, multivitamin and avoid aggressive exercise/ stress related activities that could effect ur current condition. At Last Must do Counseling here. (Must explain preliminary immpression, use few medical term but explains in easy language)  Beside that I also have some imp concerns regarding ur health which I like to talk. > than do counseling/ explain.  I also like you to understand that we are here to support and comfort you in every possible manner.  Ok Mr. Brown I am looking forward to see you again, Take care and good bye. shake hand. (DONE GOOD LUCK) If you have no time left, before leaving the room just say you will do rest later today. It is very very important that u show compassion / concern in ur words and gesture. (be dramatic but wisely) ````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````````

HOW TO SYMPATHIZE : I understand that must be very agonizing and distressful experience for you. I understand some time things are very tormenting & distressful. I understand some times things are very unpleasant & heart breaking or annoying/ frustrating / irritating. COUNSELLING --------- "R.E.V.I.C.E". (can be done in any order partly through out encounter or at last) * Reassurance (I would like to assure you that ur in good hands & I will do my level best to help u) * Expectations (How do u feel about your health / if needed ask what do you think it is) * Validating Response (Your reaction is ok I would had the same response if I were on your place) * Information sharing (Explain all possible dx and future procedure. Do Awareness / prevention) * Concerns (Do you have any concern regarding your health / Do you have any Qs) * Empathic (I know how upsetting this is to you.)

Examples of "R.E.V.I.C.E": Well Mr. Smith according to info that u have provided me I think Don has some Infectious process going on (explain it) At this point I cannot Rule out any other possibilities / complication. There fore Mr. Doug I would like you to bring Don to the hospital as soon as possible, so I can perform a physical exam and order some Routine test to rule out any potential problem. Do you have any transportation problem? --- OK for that I like to forward you to talk to our Social service personnel so they can arrange you a ride to hospital. They also deal with financial concerns in case if you have one. In the mean time I would ask you to keep watchful eye on the kid, if he develops any sign of deterioration such as Change in skin color, difficulty breathing, Non responsive state, Absence of movement, than plz call 911 immediately. Age could play a role in sexual dysfunction but there are also many other reversible possibilities, hormonal imbalance is one of them. For that reason I am indicating some tests and procedure to make sure that we are not missing any cause. ‘ I understand that you are anxious and perhaps scared of surgery most ppl feel nervousness when they hear that. At this point I can not

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KICK THE BOARDS. USMLE STEP 2 CS.

IRFANMIR “15 MINUTES CONVERSATION” NOTES

exclude the possibility of surgery and I would advice you to wait for the results, as soon as the results come in I would like to sit with you to discuss all the concerns and TX option available. I understand it is very awkward and uncomfortable revealing your medical condition to others. In order to protect u & your love ones, u must inform her so we can run a test on her too, to rule out infectivity & provide future TX/ prevention. Job problem: I am more concern about your health at this point and if you want I can write a letter to your employer to explain how imp it is for you to see specialist and for that reason your absence in office. I understand that you are in difficult & painful situation but I just want to ask you few quick Qs and relevant physical exam, so I can better understand ur condition and get right medication for you. Let me drape u to make u more comfortable. I will be glad to write a letter for u but first I have to ask u some Qs and do physical examination for the better understanding of ur problem. Is that OK? MAMMOGRAM/ PAP SMEAR: Ms Jane it is highly recommended to have a mammogram. Mammogram is a modified xrays that give images of inside breast which help us detectin-g any potential problem. Is that ok? PELVIC EXAM : Later today I will perform Pelvic exam which include Observation & Palpation to look for any abnormality. Also sample taking for Pap Smear (explain pap smear), is that OK? It is highly recommended Ms Jane, In Pap Smear we take some samples of inside vagina which we call cervix than those samples are further evaluated under microscope to see whether there is any potential problem. ALCOHOL/ SMOKES: Ms Jane I am also concerned about your smoking habit. There are several options available that make quitting which include patches and medication, Remember quit smoking will improves your health; it even reverses some problems if done in time. Have u ever think quitting smokes? > Please give yourself a thought and in next meeting I will talk in more detail about it. Ok? Ms Jane I also feel that u must think about quitting Etoh; There are several options available that help quitting which include, Alcohol anonymous program, Support group & also by medication. Remember quitting alcohol improve ur health, it even reverses some problems if done in time. Have u ever think quitting alcohol? > Plz give yourself a thought & in next meeting I will talk in more detail about it. Ok? BARRIER CONTRACEPTIVES: Ms Carla I highly recommend barrier contraceptives such as Male or female condoms, which not only gives protection against possible transmission of Potential life threatening Infectious disease such as Aids, Hepatitis and syphilis but also prevent pregnancy 99% of the time. HRT: It is important to measure your Hormones, it detects chemical disturbance if there is any and also help us measuring the dose of HRT. Remember HRT will help us prevents osteoporosis (thinning of bones), mood swing, Hot flashes. Etc WT BEARING EXERCISE: Ms Jane I recommend you to have some light wt bearing exercise which help strengthen the bones and also help slow down the process of Osteoporosis (thinning of bones). I would also recommend you to take Ca++ supplement and Multivitamins. Which help rebuilding bones. RECTAL EXAM: Later today I will perform a Rectal exam, which include finger insertion inside rectum to feel any potential abnormality such as size of prostate/ Cancer. Is that OK? (if u have time u can add by saying thisprocedure is little uncomfortable but not painful)

ORTHOSTATICS: Later today I will also perform your orthostatic BP (explain it) and other exam.

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KICK THE BOARDS. USMLE STEP 2 CS.

IRFANMIR “15 MINUTES CONVERSATION” NOTES

OBESITY: I am concern about ur wt, it seems to me higher for your age and height. Have u ever been on diet? well Mr Smith I would like u to seriously consider abt having diet for wt loss because over wt can cause serious condition such as Heart/ vascular problem, sleeping problem, breathing problems, Fatigue, Bone pain, even tumors. Please give yourself a serious thought and in next meeting I will talk in more detail about it. Ok? PHYSICAL ABUSE: Ms Smith I am concern about your security at home, I like you to talk with your family/ friends and inform them about your situation and concern. I also want you to plan some exit strategy in case you feel imminent threat to your safety. In addition I will leave my Tel # in case u need it, feel free to call me immediately. Remember no one has right to hurt you physically/ mentally. Would u like to meet our social worker to help u in this? DIET FOOD/ HEALTHY FOOD: Mr Smith I think your diet is the one of the cause of your Sxs, I like you to consider seriously about Diet change, such as eating healthy food / vegetable/ and food rich in fiber etc. This will help you resolve many things specially the constipation that you have. Mr Smith I Think you must think about diet that is low in cholesterol and salt, this will help you controlling lots of your core issues such as high cholesterol/ obesity/ vascular problems etc. EXERCISE: Mr Smith I also like u to have reg exercise which will improve ur health in terms of mobility/ better circulation/ mood etc TRAVEL: Mr Smith did you get your vaccination completed before you travel. > Which ones ? Mr Smith I want you to have some vaccination and prophylaxis before you travel, such as HBV/ Pneumonia/ YFV etc and also Antimalarial prophylaxis. OK ? DO I HAVE CANCER: Well Mr Smith this is one of the possibility and since you have + ve family Hx, I will make sure that I am indicating all the necessary tests to rule out this potential cause. OK? Is that answered your Q ? WILL I LOSE MY UTERUS: Well Ms Carla, Even though chances are too low for this possibility, I will make sure that I will indicate all the necessary test and procedures to rule out your concern, Ok ? Is that ans your Q ? (later do counseling for procedure that you will indicate) Talkative pt: Sorry Mrs. Brown I understand how imp those issue are for you but I am more concern about your current health situation; so lets talk about your health for now. Silent Pt: I understand u going through tough time, would you like to share with me, I am here to help you (little pause) together we can do it. (Offer napkin waits for 2 or 3 seconds and ask what make u feel this way) I understand this must have been very difficult time for you. Please tell me more about it. I understand you feel sad would you like to tell me about it.

RECOGNIZING RESPONSES TO THE SP :

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KICK THE BOARDS. USMLE STEP 2 CS.

IRFANMIR “15 MINUTES CONVERSATION” NOTES

1- Mr. Smith: I see you’re coughing, May I give you water or napkin? 2- Mr. Smith: I see a lesion on your face, what is that? how that happen? 3- Mr. Smith: I see you’re holding your chest, are you in pain? Is there any thing I can do comfort u? 4- Mr. Smith: I see your hand is shaking, how long u have this condition? 5- Mr. Smith I noticed that ur speaking in very low voice, Is there any reason for this? 6- Mr. Smith I noticed that ur eyes are closed, Is that light is bothering u? Ask further about it. May I dim the lights? 7- Mr. Smith I noticed u r little flaccid, is there any reason for it? Are u feeling any weakness? 8- Mr. Smith I noticed that ur little anxious, is there any reason for it? Do u have any concern? 9- Mr. Smith I noticed u r wearing this maxican hat, have u traveled some where recently? 10- Mr Smith I noticed that ur holding both hand b/w ur thigh, are u cold? You should recognize and respond to any obvious acting immediately. “Remember every action of the SP is “PURPOSEFUL”. • Be careful with the pts that have Hearing Problems: don’t ask questions while you’re washing your hand because they’re not going to be able to hear what you’re talking about. • Remember to offer a glass of water in a pt that has a cough. • Remember to use Fundoscopy in : HTN, DM, and Visual complaints. • PREGNANCY : regardless of the menstrual Hx given by the pt, suspect pregnancy in a woman of childbearing age who has unexplained weight gain. • In a back pain or musculoskeletal pain we should start the HPI with the age and the occupation of the pt. • Remember Passing out = spell = blackout = LOC = syncope • Any case of abdominal pain, remember to ask about relation of the pain with food intake. • Remember says: thank you Mr. Smith you have been very cooperative. I have tested all your CN and they’re all right. • Epigastric pain ask about: jaundice, black stools, blood on the stools, postprandial fullness (bloating), early satiety. • Trembling hands = tremor sweaty palms = sweating , shakiness = seizures • Remember in any case of LOC , ask about : Did you passed urine or stools without your knowledge? • Dark Urine: Ask did u eat any food that could cause this change in color (berries, colored candy, beets, B comp?) • Remember to ask in any case of dark stool: Have you taken any iron supplements, beets, or Pepto-Bismol ? • Remember any pt with “ Chest Pain” : on workup , include: Cardiac Stress Test( treadmill) • Remember to ask in any case of fatigue about: bruises, rash, hair loss, cold or heat intolerance, sexual interest( sexual drive), any change in voice( hoarseness), any support system at home( from families or friends) • Pulses: 2/4 = normal, 3/4 = full , 4/4 = bounding (aneurysm, calcification) • Depression, insomnia or fatigue, Ask: Do u have anyone who can provide support and care u need at home? • s/p = previous condition , Stat = immediately, capillary refill ,nl = < 5 secs.

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KICK THE BOARDS. USMLE STEP 2 CS.

IRFANMIR “15 MINUTES CONVERSATION” NOTES

IMPORTANT NOTES : Don’t raise eye brows or frown. Avoid phrases or words like “Good”. A simple “Thank you” or “Okay” is often sufficient. Patient should not feel rushed. Quietly wait for the patient to complete each answer. Don’t fill in words for the patient; the answer should be in his or her own words. Remain connected and purposeful during physical examination DO NOT shake hands if pt lying down in pain or shoulder pain DO NOT say the diagnosis first thinking that you can explain it after...SP jump and say what is that? DO NOT SAY trauma...say accident. DO NOT give your back while washing hands DO NOT SAY ...I don’t know....say I do not know YET DO NOT ignore pt efforts to take care of his health....congratulate him DO NOT RUSH during the first 1 or 2 minutes,....take time so SP adapt to you DO NOT stay stand up if pt is laying down,...is better if you seat and your eyes are same level to pt. DO NOT forget to reassure and use the word.....let me assure you.... DO NOT move the pt unnecessarily...or too much DO NOT write the chief complain in medical terms DO NOT forget to say....DID that answer your question...do you have another question DO NOT forget to paraphrasing. DO NOT use leading questions/ DO NOT repeat questions. DO NOT put the pen in your mouth......careful if u have this tendency DO NOT sound like robot. DO NOT say ok to everything....are your parents alive? No my dad has cancer....OK DO NOT be afraid to make the pt repeat if he said something that you could not understood DO NOT forget about the impact of the illness in his personal life HISTORY PEARLS 1 - Ask about thyroid symptoms in: weight changes, depression, amenorrhea 2 - Abdominal pain: ask about black or tarry stools 3 - Abuse: ask about emergency plan, if family and/or friends know about what's going on 4 - Bruise, depression: ask about abuse 5 - Chronic cough: ask about HIV, TB, ACE inhibitors use 6 - CNS case: ask about previous stroke, migraine, seizures, syphilis 7 - Dizziness: ask about tendency to fall towards left or right 8 - Depression: ask about guns and pills at home, auditory hallucinations 9 - DM: ask about vision, sensation, ED, counsel about foot care 10 - Forgetfulness: ask about ADLs (activity of daily living), social support, head trauma, depression, syphilis 11 - Jaundice: ask about urine and stools color 12 - Hearing loss: ask about exposure to loud noises 13 - If you have to say "I don't know", say "I don't know yet!" 14 - Insomnia: ask if the problem is falling asleep, staying asleep or waking from sleep; frequent movements of legs, hot flushes; order sleep diary for 2 wks (rule out obesity/ snore / difficulty breathing) 15 - Menopause: ask about mood swings, family breast / uterine cancer history; counsel about weight bearing exercises (osteoporosis) 16 - Palpitations, insomnia: ask about caffeine intake 17 - Ob/gyn case: ask details about periods, cycles, intercourse, pap smear 18 - Rash: ask about sun exposure, ticks, mosquitoes bites 19 - Pain in hand: ask about repetitive movements, such as operating a key board 20 - Obesity: ask about joint pain, hypercholesterolemia (Rule out Insomnia/ snore/ difficulty breathing) 21 - SOB: ask about wheezing, orthopnea, PND 22 - Swelling: ask about diurnal variation 23 - Psychiatric cases: always check social support, offer social worker help 24 - Thyroid problem: ask about change in voice

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KICK THE BOARDS. USMLE STEP 2 CS.

IRFANMIR “15 MINUTES CONVERSATION” NOTES

25 - Trauma in elderly: ask about abuse 26 - Vomiting: ask about fever, headache, if it is projectile; if yes for any, do a fundoscopy PE pearls 1 - Any bleeding: order orthostatics 2 - DM: fundoscopy, test sensation and vibration, pulses, auscultate carotids, examine feet 3 - Dizziness: order orthostatics 4 - COPD: check sinus, do a complete cardiologic exam 5 - Confusion, forgetfulness: auscultate carotids, MMSE, fundoscopy 6 - Insomnia: check thyroid, DTRs 7 - Lower back pain: straight leg raising test, lumbosacral range of motion, gait, order rectal exam including "saddle area" sensory exam, DTRs in legs 8 - Palpitations: check thyroid, extremities tremor, DTRs ----------------------------------------------------------------------------------------------------------------------------------------------

HISTORY TAKING : Start with OLDFPQIR (OLD Fat Patient Querulous In Room) PAIN : O 1. When did it start ? (after this always ask, Please tell me more about it? / How did it start?) L 2. Where exactly the pain is can you show me with one finger? D 3. How long does it last? F 4. How frequent pain appears (how frequent it comes and go) P 5. Is it progressive? (or getting better/ same) Q 6 . What is the pain like? How does pain feel like ? I 7. On the scale of 1 to 10 where 10 is worst pain of ur life, how do u grade ur pain? R 8. Does pain travel to other part of ur body? All /Exa: what do u do to make it better. What makes it worst? 9. How do u feel about it? >>> Ask how do pt feel abt it & than must Sympathize here >>>>>>>> Must sympathize again must sympathize here Must sympathize here >> Must sympathize again > Must sympathize here must sympathize here >> Must sympathize again >>>>>>>> Must sympathize here > Must sympathize again >>>>>> Must sympathize here >>>> Must sympathize here >> ROUTINE CARE: 1. Are ur child’s immunization up to date? 2. When was the last routine check of ur child? > how was that? 3. Has ur child had any serious illness beside the current problem? 4. Is ur child taking any medication? 5. Does ur child have any allergies? 6. Has ur child ever been hospitalized/ any surgeries? 7. Is there any disorder or illness runs in the parents or relative? 8. Does he go to Day care or school?

FEEDING HX: 1. Did u breast feed ur child? > for how long? 2. when he started the formula? > Is it fortified with Iron? > Is he taking Pediatric Multivitamins? 3. How is ur Childs appetite? > When did ur child start eating solid food? PREGNANCY HX: 1. Was ur pregnancy full term? > Did u have routine check up during ur pregnancy? 3. Did u receive U/S evaluation during pregnancy? How was the result? 4. Did u have any complication during pregnancy? 5. Any complication during birth process or after it? 6. Was it normal delivery or C-section? 7. Did u use any medication during pregnancy? 8. Did u smoke or drink during pregnancy? Did u use any Illicit drugs? 9. Did ur child have any medical problem after birth? 10. When did ur child have first bowel movement? 11. Were all the milestones on time and appropriate? (such as Smile/roll over/ sit crawl/talk/walk/dress/laces/hop etc) 1. Acknowledge her efforts in care. > 2. Counseling and awareness is very imp in this case. 3. Explain ur impression what could happen possibly. 4. Counsel about OTC medication if needed TRAVEL Hx: 1. Have u traveled recently? Or Do u have travel plans? (if yes where and r u vaccinated don’t forget counseling) ---------------------------------------------------------------------------------------------------------------------------------------------

Start with OLDFPQIR (OLD Fat Patient Querulous In Room)

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IRFANMIR “15 MINUTES CONVERSATION” NOTES

O (onset) ------------ When did it start ? How long you are having pain ? (Also ask how did ur pain start? imp) L (location) -------- Could you plz point it with one finger where exactly do u feel it ? D (duration) -------- How long does it last ? How long does single episode last ? F (frequency) ------- How frequent is it ? (Constant vs. Intermittent) P (progression) ---- Is it getting Better or Worst or Same ? Q (quality) ---------- Can u describe the pain how is it like ? I (intensity) --------- Scale of 1/10. R (radiation) ------- Does it travel to some other part of the body ? All/Exa F ------------ What makes it better ? What makes it worst ? >>>> Must sympathize at this point.