Saturday, April 9, 2016

Step 2 CS: Transition phrases

Once you are done with History, do a Review Of Systems:

Transition phrase: "Just for the sake of completion, I would like to ask you a few more questions - You can answer these questions with a 'Yes' or a 'No'."

These are the questions I would usually ask:
Any changes in your Weight?
Any Appetite changes?
Any changes in your Diet?

Do you have any Fever? (Night sweats / Chills)
Any changes in your Urinary habits?

Gastrointestinal complaints:
Any abdominal pain?
Any diarrhea or constipation?
Any nausea?

Then optional:
Any headache?
Do you have blurry vision?
Any weakness or numbness?

Any chest pain?
Shortness of breath?
Any feeling that your heart is beating really fast in your chest?

Any changes in your skin?
Do you feel like you can not tolerate the temperature in the room?

Now, ask for past medical history. Transitional phrase: "Now I would like to ask you a few questions about your past medical history."

Past medical / Past surgical
Family history
Social history

Transitional phrase before social history: "I'd like to ask you some personal questions which might be important, rest assured I will keep this completely confidential."

Do you smoke?
Do you drink alcohol?
Any illicit drugs?

Have you traveled anywhere recently?
What do you do for a living?
Do you exercise?
Are you sexually active? (More about sexual history here)

"With your permission, I would like to examine you. Is that okay with you? Please excuse me while I wash my hands."

While washing hands, talk something! Ask him about his occupation -
"Ooh fashion designer, must be interesting."
"What do you study?"
"So you sing huh? Do you play music too?"
If you don't know what to say, just ask, "Are you allergic to sanitizers?"

Then STICQ. (Read more about it here.)

"Thank you for letting me examine you and for being so co-operative."

"Your cough would be caused due to a number of reasons but most likely it is due to tuberculosis. Tb is an infection of your lungs. I would like to do some blood work and imaging to diagnose it."

"I would also like to advise you to quit smoking since it is injurious to your health. Have you considered quitting smoking? I understand it's very hard but we have excellent programs that can help you quit."

"Do you have any questions or concerns?"

1 comment:

  1. this is beautiful. Your blog has helped me through step 1 and now with Step 2! Keep up with the good work!


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