Good morning, Mr. smith?

I'm Dr Matched and Happy, I am here to see you as your physician today, is
everything in the room ok for you?

Let me make you more comfortable.

Mr. Smith, please tell me how can I help you.

I am sorry to hear that, I shall try my best to help you, Hope you don't mind If I
make a few notes as you speak.

L Location.

I Intensity.

Q Quality .

O Onset + Progression.

R Radiation .

A Associated Symptoms.

A Alleviating Factors.

A Aggravating Factors.

P Previous Episodes.

D Duration.

F Frequency.

Transition: Now Mr. Smith I am going to ask you some questions about your health
in general.

P Past Medical History.

A Allergy History.

M Medications.

H Hospitalizations.

U Urinary Problems.

G GI Problems.
S Sleep .

Transition: Thank you Mr. Smith, now let's talk about your family's health.

F Family.

Transition: Now I need to ask you some personal questions, let me remind you that
everything you tell me will be kept confidential. Is that okay with you?

O OB/GYN.

S Sexual.

S Social:

O Occupation.

Transition: Now tell me a bit about your lifestyle.

S Smoking.

A Alcohol.

D Drugs.

Is there anything else you want to tell me?

Thank you for answering these questions. Now I will perform a quick general
examination and then look at your chest, is that fine? Excuse me for a minute to
wash my hands.
Well Mr. Smith, let's start with your eyes…

Okay Mr. Smith, thank you for your cooperation, now I'd like to tell you what I'm
considering so far, first let me summarize, You told me that you have had over
the past you have also said that and that . You said that your mother
and your sister had (Details of history). In the physical exam I observed that
and that .

So Mr. Smith, based on what you told me and the findings on your physical exam, I
think this problem may involve your , there are diagnostic possibilities like
, , and , (explain disease), to be more certain I will order a few
tests, I'd like to see the results of a and a , as soon as I get the results of
these tests we'll have a better idea about your case and we'll sit down together to
discuss the results and go over the various treatment options, is that okay with
you?

Also I would like to talk to you about (counseling).

Do you have any questions?

Are there any special concerns you have?

Well, Thank you very much Mr. Smith, I'm glad I was able to work with you and I
remember that I am always here to help you, thank you for your cooperation, I will
be leaving now, have a good day.

LATE.
Oh Mr. Smith, we have an emergency and I have to leave, I will see you as soon as
can, I'm really sorry.

NO ANSWER.

I understand the sensitive nature of these questions but be assured that whatever
you tell me will be kept confidential, there may be important clues coming from
kind of information and I want to do my best to help you, shall we try answering
these questions again?

Ok Mr. Smith, now let me begin by…

Ok Mr. Smith, now I am going to start by examining your head, let me look at your
head first…

Now I am going to press on your head and cheeks to examine your sinuses, let me
know if you feel any pain.

I am going to check your eyes, can you look up for me please?

Mr. Smith, please look ahead, I am going to shine this light on your eyes.

Mrs. Clark, I'd like you to follow my finger (or pen) with your eyes only, please don't
move your head, follow it out here…

Fundoscopy:

Mr. Clark could you look to a fixed point in the wall please?

Mr. Clark could you look direct to the light?

Mr. X. Could you open your mouth for me please? Stick out your tongue.

Say Ah.

Now I am going to check for swollen glands, let me know if you have any discomfort
with this.

I am going to touch your thyroid, the gland in front of your neck, I need you to
swallow when I ask you please,… swallow.

Now I am going to listen to you neck, can you hold your breath for a moment…
thank you.
Now let me check your heart First, I am going to touch your chest to feel your heart
impulse.

Now I am going to listen to your heart.

Lungs.
Could you say 99 please? Again, again…

I am going to tap on your back .

I am going to listen to your lungs, please take a deep breath, , again, again… Ok,
now breath normally, Thanks.

ABDOMEN.

Mr. X, let me uncover your belly to examine it.

Now please, let me listen to your bowel sounds.

Any tenderness here?

Quick Minimental.

Mrs. Smith, I am going to ask you few questions

to asses your attention and memory ok?

Orientation:
Can you please tell me your full name?

What is the date today?

Can you tell me where are you now?

Memory:

Mrs. Smith please repeat after me? Table, pencil, purse. (Immediate recall).

I am going to ask you to recall these words later ok.

Attention & Concentration:

Now spell the word "WORLD" backward for me please?

Language Test.

Can you close your eyes put your hands together and bring them on to

your belly and then on to your back?

Mrs. Smith I want you to recall the 3 words that I told you few minutes ago.

Mr. X, I'm going to touch some places on your face with it, I want you to close your
eyes and point at where I just touched you.

Can you bite real hard?

Now you can relax.

Smile for me please?

Could you frown for me?

Shrug your shoulders.

Stick out your tongue, move it to the right, now to the left.

Sensory Function:

Close your eyes, this is dull and this is sharp.

What is this? sharp or dull?

Reflexes.

Now Mr. Smith I am going to tap your knees and elbows to check your reflexes.

Motor function.

Grip my hand, press…relax.

bring your arms in front up like this….push up, down, relax.

Knees and lower legs.

Push up, relax; push down, relax.

Press forward, press backward.

Cerebellar function.

I am going to place my finger here, please touch my finger and then touch your
nose .

Please stand still with feet together and put your arms in front of you, I will be right
beside you in case you feel unsteady.

Can you walk to the door and back please?

Counseling

Smoking:

Mr. Smith, I would like you to know that smoking is harmful for your health. Using
tobacco products can lead to heart disease, lung disease, blood vessel damage and
more complicated conditions like cancer.
Have you ever considered quitting? … Would you like to quit smoking?

Yes: Great, let's make an appointment for next week and we will start this process.
There are many resources we can use to make this easier for you.

No: Remember I am here to help you, if you want to quit smoking just let me know.

Safe Sex:

Mr. Smith, Using condoms can prevent sexually transmitted diseases like hepatitis
B, HIV and many other conditions, I would recommend that you use them every
time you have sexual intercourse to protect your health.

High Cholesterol, Bad diet:

Mr. Smith, based on what you told me, I think you should consider changing your
diet to prevent damage to your blood vessels and heart disease. Lowering the
amount of salt, fat and junk food and including more vegetables and fruits in your
diet can help you have a better health.

Constipation:
Mr. Smith, based on what you told me, I think you should consider changing your
diet and include more fiber and vegetables to improve your bowel health. Try to
lower the amount of red meat and fat you eat, I am sure that would really help you
be more comfortable and healthy.

Alcohol:

Mr. Smith, I would like you to know that alcohol is harmful for your health. Using
alcohol can lead to blood vessel disease and heart disease among many other
conditions and you are at an increased risk of injury when you are under the
influence of these substances.
Have you ever considered quitting? … Would you like to quit drinking?

Yes: Great, let's start you on this process. There are many resources we can use to
make this easier for you and I will help you in every step of it.

No: Remember I am here to help you, if you want to quit drinking just let me know.

Alcoholic:

After the first part:

Mr. Smith, Based on what you told me, I think you have difficulties that may be
caused by alcohol. I recommend you start on a quitting program as soon as possible
to protect your health, are you interested?

Yes: Great, let's start you on this process. There are many resources we can use to
make this easier for you and I will help you in every step of it.

No: Remember I am here to help you, if you want to quit drinking just let me know.

Depression:

Mr. Smith, I know you feel sad and I am here to help you, I will start you on
treatment as soon as we have the results of some tests to improve your condition.
Remember I am here to help you and you can contact me anytime. If you ever feel
like you want to hurt yourself or others call me immediately or go to the nearest
emergency department and call me. Do you understand? … Ok, remember you
are not alone, we have many resources to help you and my main goal is your
recovery.

Domestic Abuse:

Mr. Smith, if you ever feel you are not safe at home please let me know, we have
many resources to assist you and you are not alone in this. I am here to help you,
you can contact me anytime.

Diabetes:
Mr. Smith, I would like to remind you that you should check your feet daily, make
sure you do not have any cuts or scratches, also, let's make an appointment with
your ophthalmologist to check your eyes. Medication is very important in your
condition, try to take your medications as directed and if you run out of medication
just let me know and remember to keep a low sugar diet. We are going to do some
tests to see how you are controlling your blood sugar and if you want, let's start you
on an exercise program to improve your health, is that ok with you?

Hypertension:
Mr. Smith, let me remind you that medication is very important in your condition,
try to take your medications as directed and if you run out of medication just let me
know, keep the salt and fat in your diet low and also, let's make an appointment
with your ophthalmologist to check your eyes, and if you want, let's start you on an
exercise program to improve your health, is that ok with you?

Drugs:
Mr. Smith, I would like you to know that (cocaine/marihuana, etc) is harmful for
your health. Using (substance) can lead to blood vessel diseases and heart disease
among many other conditions and you are at an increased risk of injury when you
are under the influence of these substances.
Have you ever considered quitting? … Would you like to quit using (substance)?

Yes: Great, let's start you on this process. There are many resources we can use to
make this easier for you and I will help you in every step of it.

No: Remember I am here to help you, if you want to quit using (substance) just let
me know.

Addict:

After the first part:

Mr. Smith, Based on what you told me, I think you have difficulties that may be
caused by (substance). I recommend you start on a quitting program as soon as
possible to protect your health, are you interested?

Yes: Great, let's start you on this process. There are many resources we can use to
make this easier for you and I will help you in every step of it.

No: Remember I am here to help you, if you want to quit using (substance) just let
me know.