CS PROTOCOL FOR A CASE OF CHRONIC CHEST PAIN 1) Knock 3 times 2) Mrs.Anderson ?

( Call pt by last name as you partially open the door) 3) Introduce your self: Good morning./afternoon Mrs. Jenny. Did I pronounce your name correctly? My name is Doctor Steve. Nice to meet you (with a smile and firm handshake). I am your attending physician today and I am here to take care of you .(eye contact) 4) (Look around the room)Is everything alright for you in this room? yes 5) Ok Let me first cover you up and make you feel little more comfortable (apply the drape over the legs) Do you feel comfortable now? Yes thank you 6) Mrs Anderson I am going to ask you few questions and then do a brief physical examination on you and I will be taking some notes as you speak. Okay? yes 7) Doc: Alright. How can I help you today? /what caused you to come in to the hospital(Open ended questions at least 4-5) SP: I have been experiencing chest pain doc Doc: Oh I am really sorry to hear that. Ill do my best to help you with this problem.( Show empathy and reassure in the beginning ,middle and at the end ) 8) Doc: Now Can you describe the pain for me / tell me more about your problem? (open ended question) 9) SP: Well its a crushing type of pain and has been going for 3 months Doc: (each time you got to paraphrase throughout the encounter as follows) Crushing type of chest pain for 3 months (while you paraphrase you need not look at the sp. you can write down notes when you do that) Mnemonic: OQRSI AAA PAM HUGS FOS SODA 10) Onset/ Intermittent or constant /Frequency/ /Progression (4 components) How long has it been going on? For 3 months Does it come and go or is it constant? It comes and goes. How long does it last? 20 minutes How often do you get the pain? About 3 times a week Does it become worse? yes (Club all 4 points together and paraphrase as follows: so it comes and goes about 3 times a week , last for 20 minutes each time and its getting worse ) yes doc 11) Quality : What is the pain like? (if the patient says I dont know) is it sharp? Burning? Pressure like? Is it dull? (One question at a time) its pressure like (paraphrase for each response through out the encounter as I have explained above 12) Radiation: Does the pain move around/travel anywhere? Yes it moves to my left arm ( To your left arm) yes thats right doc 13) Site:

Can you show me exactly where do you feel the pain? 14) Intensity: On a scale of 0-10, with 10 being the worst pain of your life, how would you rate your pain? 7/10 (show empathy. It must be pretty bad) 15) Aggravating factor: What makes the pain worse? Walking the dog 16) Alleviating factors What makes the pain better? Resting. (Paraphrase now: so walking the dog and climbing stairs makes it worse and resting makes it better yes thats right doc 17) Associated symptoms: Open ended question: Do you have any other symptoms other than chest pain? No doc. Now ask specifically- Do you have any SOB? How about cough, how about fever? Any stomach pain? Any N and V? Change in bowel, any leg swelling ect 18) How this pain has affected your day today life? Well I really cannot do my daily routine activities like walking to the mall walking the dog and I am really frustrated. (I understand. It must have been hard for you ) 19) Transition : Now I need to ask questions about your past medical illnesses 20) Past medical history: (PMH) Have you had similar pain before? Not before 3 months Have you had any other medical illnesses in the past? (Yes I have had STDs), how about high blood pressure, how about asthma? How about high cholesterol? (each separately!!) and ask for duration and paraphrase as follows :HTN for 3 year, Stds 3 months ago yes doc 21) Allergies : Do you have any allergies for any medications? No 22) Medicines : Are you currently taking any medications? Are you taking any over the counter medications? Can you show me the prescription? Paraphrase 23) Hospitalization(PSH): Have you ever been hospitalized before? Have you undergone any surgeries before? Have you had any accidents or injuries in the past? Paraphrase 24) Urinary habits Have there been any changes in your urinary habits? Paraphrase 25) GIT habits: Have there been any changes in your bowel habits? (Follow up question and paraphrase) 26) Sleep: /Appetite/Weight loss Have there been any changes in your sleeping pattern (If yes) How many hours do you sleep.( Empathize: it must be pretty hard for you to sleep when you are in pain ) Any changes in your appetite? Yes I have lost appetite Any changes in your weight (open ended Q) yes I am losing weight doc

How much have you lost? About 15 pounds. Over what period of time? In 6 months. (paraphrase: So you have lost 15pounds in 6 months. Yes thats right. 27) Transition: let me ask some questions about your family history 28) Family history: Does anyone in your family have any medical illnesses? No Are your parents alive? No Do you have anybody at home to take care of you and to provide support? no So you must be feeling very lonely at home? Yes doc 29) Obstetric and GYN history: irrelevant 30) Transition: let me ask some questions about your sexual health and practices 31) Sexual history: Are you currently sexually active? Who is your sexual partner? are they men, women or both? Do you use condoms consistently? Have you ever had any sexually transmitted ds?(this will be revealed in PMH so dont ask again) 32) Counsel briefly for high risk sexual behavior and prevention of STD Mrs Anderson since you said you dont always use condoms I am very much concerned that you might be putting yourself at risk of STDs. So I would advise you to use condoms consistently to prevent STDs and unwanted pregnancy. Period. dont explain too much . 33) Transition : Now let me ask some question about your social life and personal habits 34) Smoking : Do you smoke? How many packs a day? How long have you been smoking? Paraphrase and counsel briefly (1 pack perday for 30 years.. Since smoking can put you at high risk of developing lung cancer and Heart attack I highly advise you to cut down your smoking eventually quit. If you are interested we have many ways to help. Okay? Period) 35) Occupation: What type of work do you do? 36) Drugs: Do you take any recreational drugs? Which one? How often. Counsel then and there so that you wont forget it. 37) Alcohol : Do you drink alcohol? What do you drink? How much do you drink per week/day? Paraphrase Ask cage question Counsel then and there briefly as above 38) Mrs Anderson thank you very much for answering my questions.

39) Now I need to do a brief physical on you. I am going to go ahead and put my gloves and get back to you, Please excuse me ( I used gloves for all encounter) 40) May I proceed now with physical examination? Points to remember during physical a) Be polite explain what you are going to do and and say thank you each time you elicit a sign ( for eg: I need to check your neck so if you could swallow for me please? Thank you . b) When you make the patient lie down ask him Are you comfortable? c) When you do that please pull the extension out d) Dont touch the patient b4 giving instruction e) When you elicit pain. Say I am sorry f) Always maintain eye contact when you elicit pain and when you explain what you are going to do 41) After you are done with examination Summarize using 4 important points as follows Alright Mrs. Steve thank you for being cooperative, let me first summarize what you have told me so far.. You said you have been experiencing chest pain on and off for last 3 months and you also mentioned that it increases on exertion and decreases at rest ( 4 points) Is that right ? 42) DD/ and Test so from what you have described and from your physical findings it looks like you might have a problem involving the blood vessels in your heart and there might be inadequate oxygen supply to your heart. But there could be other conditions causing your pain. So In order to pinpoint the exact cause I need to run some blood test and Order an X ray of your chest and measure the electrical activity of your heart. Once we get the test results we can talk about what is going on with you and about the best possible way to manage your problem 43) Patient education/suggestion: In the mean time I would strongly advise you to cut down smoking and eventually quit. If you are interested we have many ways to help you. 44) Show empathy once again and reassure: I understand that you must be very much worried about your heart I want to let you know that I am going to do my best to help you. ( dont say we will definitely cure your condition- no false reassurance) 45) Do you have any questions or concerns for me?? No alright it was nice meeting you. my nurse will be here in few minutes to take

sample of your blood. We will meet gain once we get the test results as soon as possible. Take care and good bye. Points to remember in CIS: Do not ask leading question Do not avoid eye contact except when paraphrasing and writing notes Be nonjudgmental (avoid words like good very good! Excellent. Instead Say ok , Thank you) Always use lay language. Dont use CT, MRI, EKG DO not interrupt the patient while he is speaking. Facilitate by saying Uhuhuhuh go ahead! Never alarm the patient All other points are highlighted in GREEN above Remember you need to get 20 out of 23 to pass CIS Kaplan check list for CIS
1)examinee knocked before entering 2)appeared professional in dress/hygiene 3)introduced self by name 4)comfortable eye contact 5)used patient name 6)Focused attention on patient 7)expressed empathy( reflected pt feeling) 8)conveyed nonjudgmental attitude ( avoid words like good, great, excellent)instead say all right, okay, thank you 9)used appropriate draping technique 10)used few open ended questions 11)used non leading questions 12)asked one question at a time 13)answered without interrupting the patient 14)paraphrased 15)used lay language ( imaging studies instead of CT MRI, Electrical study instead of ecg 16)used transitional phrases 17)gave explanation during physical 18)appropriate reassurance 19)summarized significant hx 20)diagnostic impression in lay term 21)discussed diagnostic test 22)asked if pt had any questions or concerns 23)patient educations/suggestion

Points to remember to pass in SEP 1) Paraphrase throughout the interview as I have explained in this case (this will help the sp understand that you can comprehend him well) 2) Summarize 3) Ask questions clearly and louder without rushing too fast (practice questions in FA) Points to remember when answering a challenging question 1) first say that you understand his concern

2) then answer the question appropriately 3) then reassure 4) For e.g.: Doc! Am I going to get better? I understand your concern mr Steve. Your recovery basically depends on your response to our treatment and your underlying condition causing these symptoms. We will do our best to help you irrespective of final diagnosis and outcome of the treatment. I am sure if you follow this pattern you are unlikely to fail this exam. Good luck