drhouse
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I red this format over n over n over.. i used same format for all the SPs.. it helped me.. I hope it will help u too
Good morning Mr. XYZ, I am Dr. ABC, one of the physician in this hospital. I am here to ask you a few questions and give you physical examination. Before that let me drape you first so you feel more comfortable
Can you tell me the reason for coming to the hospital today?
Can you tell me more about it?
About pain ( you can fit LIQORAAA in any case, I did same thing)
L: can you tell me where does it hurt?
I: on the scale of 1 to 10, 1 being …………… and 10 being the most severe pain, which no. best describes your pain?
Q: How would you describe your pain?
O: --when did it start?
-- How did it start?
-- how has it progressed over this period?
-- Is it continuous or intermittent?
If intermittent
--how frequently do u have such episodes?
--how long does it last?
-- is there anything that might have brought this in?
-- What where you doing when this pain started?
-- Did you take any medications to get relief?
-- Did it help?
R: Does it move any where else?
A: is there anything that makes your pain better?
A: is there anything that makes your pain worse?
W: Have you noticed any change in your weight?
How many pounds did you lost?
Over what period?
Summarize the wt…… so you have lost 10 pounds in 3 months..
A: How about your appetite?
B: How is your bowel function?
B: How is your bladder function?
Summarize chief complain and other important points…
Now I will ask a few question regarding your health in past. Is that okay with you?
P-
S- Did you have similar complain in the past?
D- Do you have high blood sugar?
H – Do you have high blood pressure?
When was it diagnosed?
What do you do to control it (your blood sugar/ blood pressure)
Do you remember the name of medication?
If patients do not remember the name of medication then ask
Do you have prescription of medication?
Do you remember dose of medication?
Are you taking your medications regularly?
Is/are medications taking care of your blood pressure?
Do you get your blood pressure checked regularly?
Do you have any other medical illness?
In old and heart patients ask about cholesterol
Have you ever got your cholesterol checked?
Was that normal?
A: Are you allergic to anything?
M : Besides this medication for high blood sugar and blood pressure (glipizide) are you taking any other medications?
In case of old female pt usually over 60 ask about
Did you receive any hormonal pills?
How about vit-D or calcium supplementation?
T: have you ever been involved in major trauma?
S: Have you ever undergone any kind of surgery?
Did you recover fully?
H: Have you ever been hospitalized?
F: does anyone in your family has similar complain?
Can you tell me about your father’s health?
Can you tell me about mother’s health?
O: OB history
Have you ever been pregnant?
How many times?
What was the outcome?
Was the delivery normal?/ what was the mode of delivery?
If CS- did you have any complain due to Sx.
GYN history
When was your LMP?
How frequently do you have periods?
Are the periods regular? (If needed)
What is the duration of each period?
How many pads do you have to change per day?
Ask about discharge if needed
When did you get your last Pap smear exam?
Was the report normal?/what was report?
S:
Are you sexually active?
Who is your sexual partner?
Did you have any other partners in the last 6 months?
If she says yes then ask following q.
Are your partners male, female or both?
Do you use any kind of contraceptive measures?
Have you ever been diagnosed with STD?
If yes then counseling
Being sexually active with multiple partners, you are at high risk of developing STD like gonorrhea, syphilis and HIV. The best thing you can do to avoid this diseases is to be sexually active with only one partner. At the same time you encourage your partner to have sex with you only. If you can’t do this you should use condom each time you have sex.
Counseling for HIV, if patient is diagnosed with STD.
Since you have been diagnosed with STD like syphilis, you are at high risk of having other serious STD like HIV. As a concern physician I would like to advice you to undergo HIV testing. Although it is completely voluntary. If you want to undergo HIV testing please let me know.
SA: Ask questions of smoking and alcohol
Alcohol CAGE questions if needed
C: have you ever tried to cut down your alcohol consumption?
A: Have ever been annoyed by the criticism made by other people about your alcohol consumption?
G: have you ever felt guilty about your alcohol consumption?
E: Have ever needed alcohol as a first thing in the morning?
Counseling for smoking:
Have you ever tried to quit smoking?
If yes…… I really appreciate that you tried to quit smoking.
If no…..as a concerned physician I would like to tell you that any amount of smoking is injurious to health. We have excellent smoking cessation program available in our hospital. So if you are willing to quit smoking please let me know.
R: Recreational drugs
Have you ever used any kind of recreational drugs?
What did you use?
How did you use it?
If injected …… did you share needle with other peoples?
If yes……. then HIV counseling
E: Exercise( counseling only if u have time)
Since you are having high blood sugar/high blood pressure/ high cholesterol. It is good for you that you exercise regularly. The simplest thing you can do is jog 30 minutes, 3 times a week.
If pt is exercising then say
I really appreciate that you are exercising regularly. It is good for your health.
D : What does your diet typically consist of?
If pt is taking high fatty diet ( only if u have time)
High amount of fatty food intake increases risk of certain diseases like heart problems and high blood pressure. So I would like to advice you to decrease intake of fatty food and at the same time you should eat more fruits and vegetables. If you want I can arrange your appointment with nutrition counselor.
For BP: diet counseling ( only if u have time)
Since you are having high blood pressure I would like to tell you that you should eat salt restricted diet
Same for high blood sugar
W: what kind of work do you do?
H: whom do you live with?( avoid this questions except psychiatric cases)
Do you have any kind of stress at home/ work?
Thank you very much for the information you gave me.
Edited by drhouse on 06/20/08 - 08:58 AM
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everybody can do it.... its just matter of time
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| ganesha123
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that s awesome dr house..!! 
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| drhouse
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thanks ganesha,, if u need i can post standard counsellings also
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everybody can do it.... its just matter of time
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| ganesha123
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i am done with c.s but i think councellings would help a lot..!!!! 
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| lakshya_0_7
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great dr.house...please do post standard counsllings also.....
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| drhouse
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yeah,,, I will post it so it will help our other friends
congrats for yr CS
Edited by drhouse on 06/20/08 - 09:00 AM
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everybody can do it.... its just matter of time
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| ganesha123
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yeah that be great..congratulations to you too...!!!
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| drhouse
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hello Lakshya.
i did not prepare separate note for counseling but i used format from note of challenging pts that i posted in this section. it is mixture of challenging pt and counseling.
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| arlete
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Yes, very good indeed! Congrats!
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Que sera sera, whatever will be will be.
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| drhouse
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thanks arlete
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