STATION #

J.D.

PLEASE CONDUCT FOCUSED HISTORY AND COUNSEL AS YOU WOULD IN PRACTICE.

INSTRUCTIONS

1 - YOU HAVE 8 MINUTES TO COMPLETE THE STATION 2 - WARNING WILL NOT BE GIVEN 3 - THERE WILL BE POST ENCOUNTER QUESTIONS

MY ACTUAL 2 MINUTES NOTES:

ACTUAL ENCOUNTER: Patient cues: POST ENCOUNTER QUESTIONS: FEEDBACK COMMENTS:

POSSIBLE APPROACH:
Possible Differentials I should think about while waiting for 2 minutes: Vascular: Infectious: Trauma: Autoimmune: Metabolic: Idiopathic/Iatrogenic: Neoplastic: Substance abuse and psychiatric: Congenital: INTRODUCTION: Hello. (First Name) (Last Name)? I am Dr. First of all, (how may I call you?) (may I call you (First Name)? I would like to begin by asking you some questions (and later on do a physical exam) so I could determine what needs to be done. CHIEF COMPLAINT: So, (First Name), what brings you in today? DOB (ASTHMA) HISTORY OF PRESENT ILLNESS: Focus on Chief Complaint Character Do you feel shortness of breath? Can you describe the nature of your breathing difficulty?

Location Onset Radiation Intensity -

Can you describe the wheeze? What time of the day is the wheeze at its worst? Where was the patient when it started? What were you doing? How did the wheeze start? Was it sudden? How did the SOB start?

How severe is the wheeze right now on a scale of 1 to 10, with 10 being the most severe? How severe is the SOB right now? Is it affecting your daily activity? Duration How long has the wheeze been going on? Is it getting worse? How long have you been SOB? Events associated nocturnal cough, decreased exercise tolerance, atopy/ ASA, NSAID sensitivity, nasal polyps Frequency Has this happened before? When? How often? Palliative factors Is there anything that makes it better? Provocative factors Is there anything that makes it worse? Previous investigations Past medical/surgical history Asthma? Atopy? Any previous hospitalization/surgery? Medications What medications are you giving him? Allergies Any known allergy? Social history Usual diet? Smokers in the home, pets, carpets, dust? Family history Asthma, allergies, eczema, rhinitis,? STANDARD Qs: (Now, I would like to ask questions that I usually ask all my other patients/parents) (Determine if age/case appropriate) PRENATAL: Did you have prenatal care? Any difficulties during the pregnancy? Any complications during it? High blood pressure, Anemia, diabetes, infection? Explore: What? How was it treated? Did you use alcohol or recreational drugs during the pregnancy? Did you smoke during the pregnancy? Was it a single pregnancy or multiple? NATAL: When was your delivery? Was it a term pregnancy? What was the method of delivery? (If, induced) Why? How long did it take? Any complications during labor like prolonged labor, ruptured water bag, fever?

NEONATAL: How was he/she at birth? (APGAR SCORE) How much was his/her weight? Any abnormalities or complications like being yellow or blue, feverish, or didnt cry immediately? Explore: What/ When/ How long? (Empathy for healthy/ unhealthy pregnancy.) Any problems as a baby? Any hospital admissions? IMMUNIZATION HX: What needles has been done so far? Does he/she have? (age appropriate immunization) NUTRITION/ OUTPUT: Tell me about his/her feeding/eating habits? Is he/she on breast or bottle feeding? How much do you give him/her each time? How many times in a day? Any solids, vitamins, iron, supplements? What? When did you start? Is it balanced diet? Any junk food? Any difficulty sucking/ swallowing? Is he/she a picky eater? Tell me about the feeding setting & facilitation? OUTPUT (BLADDER/ BOWEL MOTIONS): How many times a day dose he/she pass water? How much each time? (Or How many wet diapers day?) Smelly urine? Red urine? How many times a day does he/she have a bowel motion? How much each time? Is it formed or loose? Smelling stool? Blood? Mucus? What color is it? Green/ yellow/ white cheesy? Explore. Does he/she control his/her bladder & bowel? (for >4 years old) DEVELOPMENT: Any delay in speech, language, or motor development? Physical: What is his/her height and weight now? Milestones Is he/she able to.. ? (Gross motor, Fine motor, Speech, Social)Age appropriate now only, no need for previous. Social/ School performance: How is his temper? Is he irritable, crying frequently? What about sleep? Does he/she attend school? What grade? Any problems at school? Any failures or suspensions? What is his/her daily routine? ENVIRONMENT: Are there similar problems with relatives, at daycare, at school?

Who is usually taking care of him/her? How are the family relationships? How has this been affecting the family? Do you feel your mood low? Any lost workdays? How are you managing with the expenses? COUNSEL: (First Name) or Mr./Ms (Last Name), let me give you some information about the .(Subject). Then EDUCATE the patient about: SRS AI OEM 1- Subject: In small chunks asking him in between: Am I making sense? or Is that clear? 2- Risk factors/ Seriousness: of not acting on the subject. (e.g Keep smoking) As you may realize, ..(Subject) causes 3- Side effects and complications of acting on the subject, emotionally and physically, and how to avoid them. There is a chance to have . as a side effect. If that happens, you can ./ call me/ go to emergency. 4- Alternatives: of acting on the subject. To deal with this, there are other options. .. 5- Investigations: Im going to send you for some (blood work and X-Ray/Ultrasound), which will help us to rule out any contraindications. 6- Outcome/ Prognosis: Clearly & truly: If treatable/successful - Assure. If severe/ chronic/ bad - Discuss family and community support. 7- Effect on patient: Now, how do you feel about that? 8- Mode of Usage: Pills, puffs, patches, injections, instruments, ..etc WRAP UP: 1- Okay (First Name) or Mr/Ms (Last Name) is there anything else youd like to tell me or ask me? 2- Negotiate with him/her an agreed upon PLAN OF ACTION. A CONTRACT. Clarify his/her and your responsibilities: Okay, so Ill send you for the investigations, you will take the medication/change your life style and report progress . 3- Follow up: I want to see you next week / in a month. 4- Last word in the interview is for the patient: Is there anything else youd like to tell me or ask me? 5- It was nice to meet you, have a nice day. DIFFERENTIAL DIAGNOSIS: Asthma Bronchiolitis Pneumonia INVESTIGATIONS:

CBC PEFR/PFT > 6y/o CXR MANAGEMENT: 0 to keep 0 saturation >92% Fluids if dehydrated Beta 2 agonists: Salbutamol 0.03 cc/kg in 3 cc NS q20 minutes by mask until improvement, then masks hourly if necessary Ipratropium bromide if severe: 1 cc added to each of first 3 salbutamol masks Steroids: prednisone (2 mg/kg in ER, then 1 mg/kg daily x 4 days) or dexamethasone (0.3 mg/kg/day)