Clinical Encounter

Psychiatric Hx and ex: Depression

Adolescent Hx and DD in practice case

Adolescent Weight loss Anorexia Nervosa Depression/anxiety Hyperthyroidism DM Cancer 

History Questions

Opening Hello Mr/Ms Smith, I’m Dr. Razavi. Nice to meet you! On the phone: Hi. My name is Dr. Razavi. Who am I speaking with? Hello Mr Smith. Are you Amber’s dad (Peds)? I’m the physician in the office today and will be taking care of you. I’m going...

Common Differential Diagnoses

Headache Migraine Cluster headache Tension Headache Temporal (giant cell) arteritis Sinusitis Subarachnoid Hemorrhage Meningitis Pseudotumor cerebri Trigeminal neuralgia Confusion/Memory Loss Vascular (multi infarct) dementia Alzheimer’s disease Normal pressure hydrocephalus Cerutzfeldt-Jakob disease Hypoglycemia Subdural hematoma Loss of Vision Retinal artery occlusion Retinal vein occlusion Acute angle-clusure glaucoma Retinal detachment Depressed...

Clinical Encounter

Doorway Information (10-20 seconds) Patient info Name Age Sex Problem Chef complaint Vital signs Blood pressure Temperature Heart rate Respiratory rate Connect with patient through PEARLS Partnership Empathy Apology Respect Legitimization Support History (7-8 minutes) Introductions Knock on the door Verify the patient’s name Introduce yourself and shake hands...

Physical Exam

HEENT Head Inspect: First I am going to inspect your head for a second. Conjunctiva: I’d like to take a look under your eyelid. Touch: May I feel around your head? If anything is uncomfortable please let me know. (I am going to press gently on your head, please let me know...

Normal Patient Note

History HPI: 37 yo male c/o blah blah On the phone: The source of information is the patient’s mother/father. The mother/father of a 6-month-old F c/o her child having blah blah ROS: Negative except as above. Allergies: NKDA Medications: None PMH: None PSH: None Ob/Gyn: G1P1, LMP 2 wks ago, menarche at...

Blue Sheets

Blue Sheet (Adults) Blue Sheet (Peds)

Mnemonics

Check for Depression SIG E CAPS Sleep Interest Guilt Energy Concentration Appetite Psychomotor (agitated/lethargic) Suicide Check for Alcoholism CAGE questionnaire Cut down Annoyed Guilt Eye opener Smoking consultation 5 A’s Ask about tobacco use Advise to quit Assess willingness Assist in quitting Arrange follow-up Respond to patient emotions PEARLS...

Miscellaneous Notes

If patient has glasses and need to examine eye take them out. Don’t abbreviate any of the 3 DD If there are no work up indicated: write “no studies indicated” Before entering room have 5 DD ready Hand wash: first run water, then soap… “I need to do a...

Official Video Screenshots

Notes to read CIS