Communication to approach | YES (1) | NO (0) | ||||
| Greets the patient |
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| Introduces himself/herself |
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| Ask patient how they'd like to be addressed |
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| Explains what they are going to do |
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| Treats the patient respectfully |
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Knowledge |
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Chief Complaint |
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| YES (1) | NO (0) | ||
| What seems to be your problem today? | I have pain in my belly |
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HPI |
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| YES (1) | NO (0) | ||
Name | Leon Sheldon |
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Age | 31 |
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What is your Occupation? | Bank teller |
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Abdominal pain OCD |
| YES (1) | NO (0) | |||
When did the pain start? | This morning |
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How did the pain start? Suddenly or gradually? | Gradually |
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What were you doing when the pain started? | I was eating my breakfast |
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| Have you ever had abdominal pain problem before? | No |
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Does the pain come and go? | It is a constant pain |
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What makes the pain better? | I feel better when I'm lying still |
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What makes the pain worse? | It is worse when I move around |
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Do meals make the pain worse? | No |
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Where was the pain when it started? | Around my belly button |
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Where is the pain now? | On the lower parts of the right side |
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What does the pain feel like? | Aching |
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Is the pain constant, or does it come and go? | it's constant |
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Is the pain sharp and continuous? | Yes |
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Is the pain cramping and intermittent? | No |
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Has the character of the pain changed since it first started? | Yes it is more severe now and the location is different |
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How severe is the pain now, on a scale of 1 - 10, where 10 is the worst pain you ever had? | 8 |
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Does the pain radiate anywhere, such as into the back, sides, or groin area? | No |
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Have you noticed any palpable mass in your groin? | No |
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Nausea and Vomiting | YES (1) | NO (0) | ||||
Have you had any nausea? | Yes |
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Have you had any vomiting? | Yes, once |
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Does the vomitus contain any blood? | No |
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Stool /Diarrhea/Bowel Habits | YES (1) | NO (0) | ||||
How are your bowel movements? | as usual |
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Have you noticed any change in your bowel habits? | No |
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Any Diarrhea? | No |
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Any Constipation? | No |
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Is there any blood in stool? | No |
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Any black tarry stools? | No |
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Appetite | YES (1) | NO (0) | ||||
Any change in your appetite? | It is much less than before |
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| Patient centered interview |
| YES (1) | NO (0) | ||
| How do you feel about it? | I am really worried |
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| Do you have any idea what the reason behind this might be? | No |
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| What effect the illness has had on your (the patient’s) life, sleep and daily activity? | I cannot do anything |
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| What do you hope I can do for you today? | I hope you can stop the pain and tell me about the diagnosis |
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Past Medical Hx |
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| YES (1) | NO (0) | ||
| Alarming/Constitutional symptoms |
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| Do you have fever? | Yes, I think so |
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| Do you have night sweats? | No |
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| Do you have chills? | No |
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| Medication |
| YES (1) | NO (0) | ||
| Are you currently on any medications? | Yes, Salbutamol as needed |
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| Why do you take this medication? | For my Asthma |
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| Allergy |
| YES (1) | NO (0) | ||
| Do you have any allergies? | No |
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| General History |
| YES (1) | NO (0) | ||
| Do you have history of any illnesses? | Yes |
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| Surgical History |
| YES (1) | NO (0) | ||
| Have you ever had a surgery? | No |
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Family Hx |
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| YES (1) | NO (0) | ||
| Is there any other medical condition in your family that I should be aware of? | No |
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Smoking, Alcohol and Drugs |
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| YES (1) | NO (0) | ||
| Do you smoke? | No |
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| Do you drink alcohol? | yes |
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| How much alcohol do you usually drink? | Occasionally |
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| Have you ever used any recreational drugs? | No |
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Personal and Social Hx |
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| YES (1) | NO (0) | ||
| What do you do for a living? | I am a bank teller |
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ROS |
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| YES (1) | NO (0) | ||
| Urinary Tract |
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| Is there any pain or burning when you pee? | No |
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| Do you feel any pain in your back? | No |
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| Do you feel any pain in your groin area? | Yes |
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Communication to Exit | YES (1) | NO (0) | ||||
| Thanks, the patient |
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Overall assessment | Score | |||||
1 | 2 | 3 | 4 | |||
| Communication (greeting, introduction, closing) |
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| Organization of interview |
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| Questioning skills (ie open ended vs closed ending) |
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| Ability to build rapport (show empathy, doesn’t interrupt) |
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TOTAL SCORE |
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