IMIGCS Course Director: Dr.

Tetiana Hliebova

Introduction to Medical
Interviewing
Clinical Skills Activity Manual for Students

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IMIGCS Course Director: Dr. Tetiana Hliebova

Contents
INTRODUCTION ....................................................................................................................................................... 3
ACTIVITY GOALS AND LEARNING OBJECTIVES ............................................................................................ 3
FORMAT ...................................................................................................................................................................... 4
DRESS CODE .............................................................................................................................................................. 4
ATTENDANCE ............................................................................................................................................................ 4
THE PATIENT INTERVIEW ................................................................................................................................... 5
THE HISTORY AND PHYSICAL WRITE-UP....................................................................................................... 5
CHIEF COMPLAINT OR CHIEF CONCERN (CC) ......................................................................................................................6
HISTORY OF PRESENT ILLNESS................................................................................................................................................6
PAST MEDICAL HISTORY ..........................................................................................................................................................8
FAMILY HISTORY ........................................................................................................................................................................8
SOCIAL HISTORY .........................................................................................................................................................................9
ROS...............................................................................................................................................................................................9
PHYSICAL EXAMINATION ....................................................................................................................................................... 10
LABS/IMAGING/ECG ............................................................................................................................................................. 10
ASSESSMENT ............................................................................................................................................................................ 11
PLAN .......................................................................................................................................................................................... 11
SUBMITTING THE WRITE-UP ON CAE LEARNING SPACE ....................................................................... 12
GRADING THE WRITE-UP .................................................................................................................................. 12
GRADING RUBRIC ................................................................................................................................................. 13
CONTACTS FOR IMIGCS ...................................................................................................................................... 13
APPENDIX A: IMIGCS OBSERVER FEEDBACK FORM ................................................................................ 15
APPENDIX B: IMIGCS SAMPLE WRITE-UP ................................................................................................... 16
APPENDIX C: CAE LEARNING SPACE® LOG-IN AND SUBMISSION INSTRUCTIONS ...................... 20
APPENDIX D: VIEWING COMMENTS ON CAE LEARNING SPACE FOR IMIGCS .................................. 24

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IMIGCS Course Director: Dr. Tetiana Hliebova

Introduction to Medical Interviewing

Guided Clinical Skills Activity
Semester 1

Introduction
As you learned in your introductory lecture, the medical history is an essential part of a physician-
patient encounter that begins several processes. The interview establishes rapport, determines
the reasons for the patient’s visit and begins a data gathering process that aids the physician in
determining possible causes for the patient’s presenting concerns. Just as an interrogation of
suspects and witnesses is essential in solving a crime, medical interviewing is essential in
establishing a patient’s diagnosis and developing a helpful management plan. When we talk
about a hypothesis-driven history, it requires you to know something about what causes people
to feel pain or experience illness in certain ways. Though you are only at the beginning of your
MD training, you have been awake and present in an age of information and will likely have some
ideas about your patient’s diagnosis based upon life experience alone. Feel free to bring in prior
knowledge and life experience into your early interviews. You will refine your work as you learn
more. The most important point to remember is that your interviewing skills must evolve toward
a thoughtful process, with questions asked not just because you are reading them off of a form
or check list, but because the answers to your questions will support or refute the various
hypotheses you are constantly forming in your mind as you hear your patient’s story.

Activity Goals and Learning Objectives

This introduction to medical interviewing has several goals – learning opportunities we will
provide. In addition, we have learning objectives for this activity – the skills we want you to be
able to demonstrate after attending these sessions.

Goals:
• To provide students with the opportunity to interview a real patient
• To provide students with practice using interview techniques with direct
observation by and feedback from clinical faculty
• To provide students with practice organizing medical history and physical
examination information in written documentation (a History and Physical, or
“H&P”)

Learning Objectives:
At the end of these sessions the student will be able to:
• Collect a medical history from a patient in an organized manner
• Organize patient medical information into a standard medical history write-up

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IMIGCS Course Director: Dr. Tetiana Hliebova

• Demonstrate some process skills in a medical interview including establishing

rapport, using open-ended and closed-ended questions effectively, using effective
transitions and segues, demonstrating empathy, eliciting the patient’s
perspective, summarizing, checking for understanding, and seeking clarification.

Format
This introductory experience allows students to have access to a patient for a medical interview,
but because the interview happens in a large group, no single student needs to feel pressured to
perform. Students should take advantage of this, listen carefully to the questions asked by others
and practice some critical appraisal of the process they are observing and how it might be
improved. All the while, faculty facilitators circulate amongst you to prompt, encourage and give
feedback on the content and process aspects of the interview. The following details the layout
and logistics of this activity.
• The patient interview begins shortly after the session starts.
• Student volunteers are chosen by the facilitator at the beginning of the session to sit next
to the patient in front of the classroom, while all others observe. Students may raise
hands when they wish to ask the patient a question. By the end of the session, a complete
history is obtained.
• Following the completion of the sessions, students are required to submit a history and
physical (H & P) write-up on CAE Learning Space® within 24 hours after the session.

Dress Code
Professional dress with white coat. Bring ID badge.

Males: Dress shirt with tie, pants, dress shoes

Females:
• Skirt/dress or pants with blouse, closed toe flats/shoes/heels
• Length of skirt/dress must be below the knee
• Blouse should not show cleavage

Attendance
This is a mandatory attendance activity. Absences will be handled in the following manner:
• Failing to attend a session with an unexcused absence will result in a significant grade
reduction of up to 30% that will jeopardize a student’s course grade and place a student
at risk of failing the CS component of the course. Students who miss an assigned session
with an excused absence are required to remediate by attending a different session.
Absences can be excused only by the Student Care team. It is the student’s responsibility

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IMIGCS Course Director: Dr. Tetiana Hliebova

to make these arrangements with rusmscateam@rossu.edu and notify Course Director,

Dr. Hliebova.
• Attendance will be taken at all sessions. Failure to bring your ID badge to all clinical
activities puts you at risk of being marked absent.
• Come to your assigned session. DO NOT CHANGE SESSIONS. Doing so impairs the
attendance process and you may be marked absent when you actually attended the
activity.

The Patient Interview

Students should plan on taking notes and may do so on computers or by hand during the session.
In practice, physicians take notes during the interview by whatever method they prefer. An
important skill is to avoid letting the pen and paper or digital equipment get between you and
your patient during the interview. You must work to maintain eye contact and an appropriate
empathic posture even when you choose to perform note-taking during the patient interview.
Constantly looking up at the patient and down at one’s notes is disconcerting to the patient and
interferes with rapport. It is wise to cultivate the habit of not taking notes and simply
remembering the history the patient has just given you. This is extremely important when the
patient interview is emotionally charged or when an empathic opportunity presents (for
example, when a patient mentions a significant emotional loss). Failure to focus your full
attention on a patient in these situations will impair your ability to be an effective physician and
it will likely impair efficiency as well. Intentional focus also affects the patient perception of being
heard and respected. You may find that even short visits are perceived as highly satisfying to
patients when they know they have your undivided attention. Finally, generous listening alone
can be therapeutic to your patient when drugs and other interventions are not available or fail.
We do not expect you to be able to avoid note taking at this early stage in your training but we
appreciate it if you try. Refer to the “Observer Feedback Form” on Canvas for guidance during
the interview or in Appendix A.

The History and Physical Write-Up

Students are required to submit a “History and Physical” write-up on CAE Learning Space by 10
P.M on the same day of the interview. See Appendix B for an example.

Purpose of H&P: H&P is required when this is your first time meeting the patient and it serves
several purposes.
• It allows for student/physician to demonstrate their ability to gather information,
incorporate their medical knowledge, and come to a conclusion about the patient and
then to form a plan.
• It is an important reference document that gives concise information about the patient
and exam findings at their initial visit.

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IMIGCS Course Director: Dr. Tetiana Hliebova

• It is a means of communicating information to all providers who are involved in the care
of the patient.
• Every H&P has the following labeled sections:
• Chief Complaint, History of Present Illness (HPI), Past Medical History, Family
History, Social History, Review of Systems (ROS), Labs/Imaging, Physical Exam,
Assessment, Plan

*Note that there are slight variations of H&P’s regarding format. The example that we provide is
the most standardized and commonly used format. As you go through your clinical rotations or
if you look at examples online, you may see slightly different formats, but ultimately they will all
cover the same content. What you will be graded on is how you organize the information and
whether the correct content is in the correct labeled sections. Students must learn the difference
between subjective and objective data.

Subjective Data vs. Objective Data:

• Subjective data: Observations that are verbally expressed by the patient such as their
symptoms, past medical history, family history, social history. Subjective information is
not measurable. It is basically what the patient tells you about himself or herself.
• Objective data: Observations that are made by you as the physician through your own
senses, physical exam, vital signs, lab results, and imaging results. Objective information
is measurable.

Chief Complaint or Chief Concern (CC)

This is a subjective statement made by the patient describing the most significant symptom or
reason that caused them to seek health care. This is usually the answer to the question “What
brings you here today?” It must be reported in patient’s own words:

“I am here for my medication refill.”

“I am here for my follow up of ________”
“My stomach hurts and I’ve been vomiting.”
“I need my blood pressure checked and I’m feeling dizzy.”
“My low back hurts.”
“I am here for my annual physical exam.”

History of Present Illness

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IMIGCS Course Director: Dr. Tetiana Hliebova

Every HPI begins with patient’s

• demographics:
o Name
o Age
o Ethnicity
o Gender

• baseline statement of health:

o previously healthy/with no significant PMH or
o with the history of something

• followed by a concise focused narrative of the patient’s presenting concern(s).

The purpose of this statement is to paint an overall picture of the patient for the reader in one
short and concise statement.
o Mr. A is a 70-year-old Caucasian male with a history of diabetes and hypertension
presents to the clinic for chest pain.
o Mr. B is a 23-year-old African-American male with a past medical history of sickle
cell disease presents to the emergency department for severe pain in the arms
and difficulty breathing.
o Mrs. C is a 46-yearoold Asian female with a strong family history of breast cancer
presents to the clinic for a lump in her breast.
o Mrs. D is a 31-year-old female with a no significant history presents to the clinic
for an annual exam.
o Mrs. E is a 65-year-old female with a history of a myocardial infarction status post
CABG surgery presents for arm weakness and slurred speech.

As you can see, the opening statement can be written with slightly different variations,
but they all have the minimal 6 pieces of information.

The Remainder of the HPI: After the opening statement, thoroughly explore the complaint in a
narrative.
o For acute cases, it is often beneficial to use mnemonic such as OLD CARTS or
OPQRST to ensure that you are gathering the required information.
o For chronic cases, you want to focus on the current management of it (if any) and
look for complications of the disease.
o For all complaints, include pertinent positives and pertinent negatives.
▪ Pertinent positives: History elements that provide evidence to support
your evolving hypotheses for the cause of the complaint
▪ Pertinent negatives: History elements that are absent, which also support
your evolving hypotheses.
▪ For example: Recall the female patient we discussed on your first day of
class. She had appendicitis, but we were also considering an ectopic
pregnancy.

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IMIGCS Course Director: Dr. Tetiana Hliebova

• Pertinent positives: Supports appendicitis

o Abdominal pain that started around umbilical area and
moved to the right lower abdomen. Patient has fever,
nausea, vomiting.
• Pertinent negatives: Refutes ectopic pregnancy
o Period is regular and last menstrual period was 3 weeks
ago.
o Patient uses contraception
o No history of STI’s or pelvic inflammatory disease (risk
factor for ectopic pregnancy)
o For all complaints, also include risk factors and any relevant history that is
discovered from past medical history, family history, social history.
▪ The reason why you want to bring forefront the relevant PMH, FH, SH to
the HPI is to provide contextual information to the reader, rather than
having them wait until the designated section to discover it. It also helps
support your evolving hypothesis. Remember, it is difficult in the beginning
for students to discern what is relevant and what is not. As you gain more
medical knowledge, you will begin to learn what is relevant and be able to
write a focused and concise HPI.

Past Medical History

This section should include the following labeled sections:

• Childhood Illnesses:
• Adult Illnesses: Previous diagnoses with year of diagnosis
• Hospitalizations: Why and when
• Allergies: List allergies and reaction if exposed (hives, anaphylaxis)
• Medications: Prescriptions, over the counter medications, vitamins, birth control, and
non-traditional therapies (herbal). Document in this form: Drug name, dose, frequency,
route
• Surgeries/Trauma/Transfusions: With approximate date/year & complications
• Ob/Gyn history: (if applicable): Last menstrual period, menses (frequency, duration, flow),
age of menarche, age of menopause, contraception use, pap smear history, pregnancies
& any complications
• Preventative care: Screening exams based on patient’s age/sex (colonoscopy,
mammogram, abdominal aortic aneurysm ultrasound)
• Psychiatric history: diagnosis and date of diagnosis
• Immunizations:

Family History

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IMIGCS Course Director: Dr. Tetiana Hliebova

This is about genetic predisposition so you want to only report blood-related family members.
DO NOT include husband or step-mother/step-father. You want a minimum of 3-4 generations
of family history illnesses. For example: Grandparents, parents, siblings, off-spring. If the family
member is healthy, state they are healthy. If the family member died, note the age and what they
died from. If the patient was diagnosed with a disease or suffered an event such as a myocardial
infarction, note the age as well. For example, if the mother had a myocardial infarction at 25
years old (which is very young for her age to have an MI), you want to note that. You want to see
if your patient is at immediate risk.

Social History

(Mnemonic “SAD TONESS”)

• Smoking/Tobacco: ___ pack/years
• Alcohol: what kind of alcohol? how much? how often?
If needed CAGE the patient.
C – Cut down - Have you ever felt you should cut down on your drinking?
A – Annoyed - Have people annoyed you by criticizing your drinking?
G – Guilty - Have you ever felt bad or guilty about your drinking?
E – Eye-opener - Have you ever had a drink first thing in the morning to steady your
nerves or to get rid of a hangover?
• Drugs:
• Travel:
• Occupation:
• Nutrition:
• Exercise:
• Sexual activity: (Active, partners, protection, practices, history of STI’s)
• Stress:
• Religion:

ROS

Refer to Canvas and see the “Review of Systems” document for the list of questions to ask for
each organ system. With some deliberate practice, you will eventually be able to memorize all of
them. Write “Patient reports/denies (symptom).” Do not write “None” or “No complaints.” You
must be specific with the symptoms that the patient has or does not have. If there is a positive,
you can briefly discuss it here, but refrain from making it lengthy. REMEMBER that all pertinent
symptoms that are relevant to CC must be reported in the HPI.

• General:
• Skin:

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IMIGCS Course Director: Dr. Tetiana Hliebova

• HEENT:
• Neck:
• Chest/Respiratory:
• Cardiovascular:
• Peripheral Vascular:
• Breasts:
• Gastrointestinal:
• Genitourinary:
• Musculoskeletal:
• Neuro/Psych:
• Male/Female Genitalia/Reproductive:

Physical Examination

For IMIGCS you will not be performing a complete physical examination on your patient.
However, you will be able to do a “general survey.”

Note that there will be more or less organ systems depending on the complaint and which exams
you decide to perform in the future. PE generally always start with vital signs. As you go through
the semester, you will learn different physical exam skills and will learn how to report findings.
• Vital Signs: BP, HR, RR, T, SpO2
• General Survey:
o Dress, grooming, and personal hygiene: Is the patient dressed appropriately for
the current temperature and weather? Disheveled?
o Signs of distress: Cardiac/respiratory distress? Anxiety? Comfortable?
o Affect/facial expression: Is there eye contact? Avoidance? Flat affect?
o Level of consciousness: Awake, alert, and responsive?
o Odors of the body and breath: Fruit odor of diabetes of scent of alcohol?
o Posture, gait, motor activity
o Skin color and obvious lesions
o Estimated height and weight
• HEENT:
• Skin:
• Cardiac:
• Respiratory:
• Abdomen:
• Urinary:
• Neurological:
• Musculoskeletal:
• Psychiatric:

Labs/imaging/ECG

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IMIGCS Course Director: Dr. Tetiana Hliebova

List of values/results. Do NOT assess, interpret, or evaluate any findings. You will not have
labs/imaging/ECG for IMIGCS so you can state “None” under this listed section. However, starting
next semester, you will have cases that have labs/imaging/ECG where you will include it here.

Assessment

Your comprehensive history (subjective information) and physical exam and lab/imaging studies
(objective findings) are the foundation of a clinical assessment. In this section, you should have a
list of “problems” where you will “assess” or discuss each one. Problems should be prioritized
with the most urgent/serious ones being first. See below for guidance.

• Acute problems: such as chest pain, shortness of breath, fatigue, abdominal pain,
etc.
o Strive to have at least 3 differential diagnoses. Discuss why you think your
#1 differential is most likely and how the others are possible, given the
information you obtained over the interview and physical
exam/labs/imaging.
o Differentials should be listed from most likely to least likely.
• Chronic problems: such as a follow up regarding diabetes, hypertension, or other
established diagnoses. Discuss the current management of it (if any) and assess
for any complications of the disease. You want to note whether you think the
disease is currently being managed properly. If not, what in your history and
physical tells you that? Restate those findings to support your evolving hypothesis.

Your assessment should be a summarization of key findings/results that lead the reader on a path
to the same conclusion you have. This conclusion can be a definitive diagnosis, a list of differential
diagnoses, and/or questions that you may still have. Make sure to support or refute your
conclusion with subjective and objective findings.

For situations where patients present with several complaints or have several problems
discovered during the history/physical exam, it’s often best to write separate assessments. Note
that these other problems may include non-medical issues that impact the patient’s health, such
as financial stress stemming from a recent job lost, or emotional stress stemming from ongoing
divorce proceedings. Try to create a problem list that prioritizes your efforts, ensuring to
document a thorough assessment. Note that you should assess EACH problem.

Plan

The plan describes what you intend to do. At this stage in your training, your plan will be limited
because you have not yet learned what you need to know about disease processes and how to
test for or treat them. Additionally, you may not know common ways of addressing other
problems that impact health, such as financial stress or alcohol abuse. At the very least you can
propose what physical exam(s) would be most helpful. If you are motivated, you can read about

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IMIGCS Course Director: Dr. Tetiana Hliebova

your patient’s presenting complaint or problems in any number of valuable resources (e.g.
UpToDate online database or Harrison’s Principles of Internal Medicine textbook) and use this
information to formulate your plan. Note that you should have a plan for EACH problem.

• Acute problems: Physical exams, lab work, imaging to rule in/out differential
diagnoses, treatment options, follow-up plans
• Chronic problems: Physical exams, lab work, imaging, medication adjustment,
follow-up plans

Submitting the Write-Up on CAE Learning Space

Write-ups must be submitted by 10 pm on the evening of the IMIGCS activity day. Instructions for
submitting the write-up on CAE Learning Space® can be found on E-college and below in Appendix
C. These include instructions for submitting your write-up in case of technical difficulties with the
Learning Space. A drop box address has been created for submission of these write-ups so that
students will have a record of the time of submission in case of difficulty submitting to CAE
Learning Space®. However, in order to have your write-up graded you must place it into CAE
Learning Space®.

Use proper English grammar and spelling for your write-ups. Some parts of the write-up may be
stated in short phrases (such as the review of systems). If you are concerned about your written
English for the write-up, feel free to have a peer copy-edit your work for grammatical and other
errors. Being able to write clearly in English are skills measured and graded, so we also emphasize
these skills and want you to improve if necessary. However, THIS IS NOT A COLLABORATIVE
WRITE-UP. You must submit your own work in your own words! Do not get together and use
another person’s notes for your own write up. Remember that plagiarism is an honor code
violation and we periodically run plagiarism software on RUSM student write-ups to screen them.
Any discovery suspicious for plagiarism will require students involved to meet with the Clinical
Foundations Chair and Assistant Chair.
The write-up is graded as follows.

Grading the Write-Up

• The write-up is graded with a numerical score and assigned Pass/Fail.
• The write-up is worth 100 points and students must receive 70% of these points to pass
the write-up part of the activity; students with lower scores may be required to re-write
and re-submit their work. A re-submitted write-up must be completed within one week
of receiving the original failing grade.
• Write-ups are graded by CSFs who complete their evaluations.
• Along with a numerical grade, constructive comments and explanations are given in order
to guide a student to improve on subsequent sessions and clinical activities.

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IMIGCS Course Director: Dr. Tetiana Hliebova

• Students must submit their own work in their own words.

• You may also check your write-up for your grade and feedback on CAE Learning Space®.
Instructions are attached in Appendix D.

If you have questions about your write-up or grade, please contact your grader directly to
review your write-up.

Grading Rubric
The general grading rubric used to review and score your write up is below:

Introduction to Medical Interviewing-Guided Clinical Skills Activity Grading Rubric Points

Demographics: Name, Age, Gender, Ethnicity, Residence 5

Chief Complaint 5

History of Present Illness: Opening statement, OLD CARTS/OPQRSTAA, & relevant PMH,
25
FH, SH, ROS (pertinent positives and pertinent negatives)
PMH: Adult Illnesses, Childhood Illnesses, Meds, Allergies, Surgeries, Hospitalizations,
Immunizations, Blood transfusions, etc. 15

FH: 3-4 generations of family illnesses 10

Social History: Smoking, alcohol, drugs, travel, occupation, sexual history, etc 10

Review of Systems: 10-12 reviewed reasonably thoroughly 10

Physical Exam (General Survey) 5

Assessment (problem list, differentials/complications) and Plan 15

Total Points 100

Contacts for IMIGCS

For scheduling issues and for help contacting your grader contact Clinical Foundations

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IMIGCS Course Director: Dr. Tetiana Hliebova

Administrative Assistants:
Ms. Melissa Remy, Email: mremy@rossu.edu
Ms. Marianna Shepherd, Email: mshepherd@rossu.edu
Ms. Ceresa Springer, Email: cspringer@rossu.edu

For communication and concerns about the IMIGCS activity:

Dr. Tetiana Hliebova, CS 1 Course Director, thliebova@rossu.edu

For assistance with CAE Learning Space® or trouble with submitting the write up:
DCM eLearning Specialist BBRusmCAETechnicalSupport@rossu.edu

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IMIGCS Course Director: Dr. Tetiana Hliebova

Appendix A: IMIGCS Observer Feedback Form

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IMIGCS Course Director: Dr. Tetiana Hliebova

Appendix B: IMIGCS Sample Write-up

Example History & Physical Exam Write-up
(Commentary written in blue is to help clarify and highlight particular points.)
Patient: Jane Smith
Age: 42
Gender: F
Race/Ethnicity: African-American
Residence: Knoxville, TN

CC: “My stomach has been hurting a lot.”

HPI:
Jane Smith is a 42 y/o African-American female with no significant history who presents today
complaining of abdominal pain (note that this is a complete opening, with all 6 components
reported: name, age, sex, race, significant history, and the cc). The patient states that the pain
began approximately 2 weeks ago and is limited to the epigastric area. She describes the pain as
burning in quality, without radiation, and rates it a 7/10 at its worse. Ms. Smith says that the
pain will usually decrease, often stopping completely, after eating a light meal. She reports
exacerbating factors such as heavy and/or fatty meals, and hunger (going several hours without
eating) (after opening statement, explore the complaint. It’s often helpful to use a mnemonic
such as OLD CARTS or OPQRST to ensure that you document most of the important content).
Patient denies a history of similar pain episodes. She does report, however, feeling nauseated at
times when the pain is present, and that she vomited for the first time yesterday afternoon. Ms.
Smith describes the vomitus as yellowish fluid and without blood. She denies
diarrhea/constipation, weight changes, or changes in her stool color/consistency/frequency
(after exploring the complaint with OLD CARTS, it’s important to note pertinent
positives/negatives that provide additional context and help us rule particular differential
diagnoses in/out.). Review of symptoms also revealed that Ms. Smith suffers from bilateral knee
arthritis, for which she takes ibuprofen 200mg, 2 tablets, 2-3x/day (only medications pertinent to
the complaint should be documented in the HPI). She denies a family history of ulcer disease but
reports that her father died at the age of 55 from pancreatic cancer. Patient also denies alcohol
and tobacco use (the final component of a thorough HPI incorporates the use of relevant past
medical/family/social history that may reveal genetic predispositions towards developing a
particular disease, or environmental factors that may be contributing to or causing the problem.).

Past Medical History:

Adult Illnesses: Osteoarthritis in bilateral knees, diagnosed 2 years ago; Urinary tract
infection diagnosed and treated 1 year ago with amoxicillin; seasonal allergies
Childhood Illnesses: reports having had chickenpox at age 5
Hospitalizations: Twice, during the birth of her 2 children, for which there were no
complications (dates and duration should be documented)
Surgical History: two C-sections (dates should be documented)

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IMIGCS Course Director: Dr. Tetiana Hliebova

Trauma: denies
Blood Transfusions: denies
Psychiatric History: denies
OB/GYN: Last menstrual period 3 weeks ago; patient reports her menses occurring every
28-30 days and lasting for 5 days; patient is Gravida 2, Para 2, with 2 elective caesarian
sections
Immunizations: reports that she is up to date
Medications:
-Ibuprofen 200mg, 2 tablets, 2-3x/day for knee pain associated with OA
-OTC multivitamin daily
-OTC loratadine PRN for seasonal allergies
Allergies: denies food or drug allergies

Family History:
Father: died at 55 secondary to pancreatic cancer
Mother: 68 y/o, reported to be in good health
Brother: 38 y/o, reported to be in good health
Grandparents: unknown
Children: 2 sons reported to be in good health
At least 3 generations must be explored, preferably grandparents/parents/siblings, as these
provide us with insight on genetic factors that might predispose our patient to developing certain
conditions/diseases.

Social History:
Ms. Smith reports living at home with her husband and 2 children. She reports being
sexually active with only her husband since marrying 8 years ago, uses condoms. Patient
denies using tobacco products, alcohol use, and illicit drug use. Ms. Smith states that she
tries eating a balanced diet, but since she works full-time as a bank manager, she or her
husband regularly buys take-out for dinner. Patient denies any new/significant stressors.
At the very least, you should document sexual history, alcohol habits, smoking habits, and any
illicit drug use. Stressors, occupation, religion, etc., are important to explore, as well, in order to
better understand our patient.

Review of Systems:
General: patient denies weight gain or loss, fever/chills
Skin: denies rashes, bruising, lesions
HEENT: denies headache, dizziness, double vision, pain, swellings
Breast: denies pain, lumps, discharge
Respiratory: denies cough, SOB, pain
Cardiovascular: denies palpitation, chest pain
Genito-Urinary: denies pain, discharge, changed in urinary frequency
Metabolic & Endocrine: no cold or heat intolerance
Locomotor: bilateral knee pain
Psychiatric: denies anxiety, depression

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IMIGCS Course Director: Dr. Tetiana Hliebova

List 10-12 systems noting pertinent positive and negatives that you explored.

Physical Exam:
General Survey: patient is appearing stated age, wearing clean and weather-appropriate
clothing, make-up, and jewelry. Patient does not appear to be in acute distress, but she is
seem rubbing her epigastrium and grimacing occasionally during the interview. Patient
can walk, sit, and stand up without apparent limitation. She speaks with an appropriate
tone/volume/rate of speech, and she was cooperative and communicated well
throughout the interview.

For IMIGCS, you will not be performing a formal physical exam. You will, however, be expected
to write a thorough General Survey, which is a component of the physical exam.

Here is an example of how this section would be organized in the traditional manner:

Physical Exam:
Vitals: BP, Pulse Rate, Respiratory Rate, Temperature
General Survey:
Cardiovascular:
Respiratory:
Abdominal:
[continue listing whichever systems you examined, documenting your results
Labs:
Imaging:

Problem 1: Abdominal Pain

DDx: Peptic Ulcer Disease, Cholecystitis, Gastritis, Gastric Cancer
Assessment: Jane Smith is a 42 y/o African-American female with no significant history
presenting today with complaints of abdominal pain. The pain is in the epigastric area,
burning, non-radiating, 7/10 at its worse, starting for the first time 2 weeks ago, and
usually starts several hours after eating. Eating light meals usually alleviates the pain, and
often eliminated it completely. She reports nausea accompanying the pain time at times,
and that she vomited yellowish fluid once yesterday. Patient denies
constipation/diarrhea/blood in stool (we summarize key history and physical exam
findings, had we performed any, to start an assessment). These symptoms are consistent
with Peptic Ulcer Disease, which the patient is susceptible to developing due to chronic
and heavy NSAID use. Other differential diagnoses to consider are Cholecystitis (patient
notes that fatty meals exacerbate the pain), Gastritis, and Gastric Cancer (patient has a
family history of pancreatic cancer).
Plan: physical exam to obtain vitals and perform a screening heart & lung exam, a general
abdominal exam, and Murphy’s Sign; Digital Rectal Exam to test stool for occult blood;
CBC with differential; AST/ALT/bilirubin/alkaline phosphatase; serum lipase; Abdominal
ultrasound; Upper endoscopy; H. pylori antibody testing; OTC ranitidine to provide

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IMIGCS Course Director: Dr. Tetiana Hliebova

symptomatic relief; discontinue Ibuprofen, as heavy NSAID use can makes this patient
susceptible to developing ulcers; return to clinic in 1 week to review labs

Problem 2: Osteoarthritis (a list of differentials is not necessary since this is a chronic and
confirmed diagnosis)
Assessment: Patient reports being diagnosed with osteoarthritis in bilateral knees 2 year
ago. She states that she takes Ibuprofen 200mg, 2 tabs, 2-3x/d. She reports that this
regimen provides adequate pain control, and that she doesn’t have any limitation in daily
activities.
Plan: physical exam of knees to assess temperature/tenderness/range of motion; obtain
XR records from previous clinic; switch to Acetaminophen 500mg capsules, 1-2 caps PO
q4-6h PRN for pain; return to clinic in 1 week to assess pain control with new medication.

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IMIGCS Course Director: Dr. Tetiana Hliebova

Appendix C: CAE Learning Space® Log-In and Submission Instructions

Login and Instructions for CAE LS Intuity® Submissions

Below are instructions on how to log on to CAE Learning Space® to submit your assignments for
the Clinical Skills Courses.

1) Go to the following web address: https://websp.rossu.edu/

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IMIGCS Course Director: Dr. Tetiana Hliebova

Legacy Login

Your initial password will be your student ID number without the “@” symbol. You may opt to
change this password as desired, but be sure not to forget it between assignments.
When you forget your password, follow the instructions below.

If you have forgotten your password, click the “Forgot your password?” link. An email should
be delivered to you within 15 minutes containing a system-generated password.
Note: if your system has been blocked, wait for 30 minutes before trying the password
received.

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IMIGCS Course Director: Dr. Tetiana Hliebova

Once you have successfully entered Learning Space, go to the Dashboard View and follow the
instructions below.
Dashboard View
In the dashboard view, select “Data Entry” for the appropriate event. For IMIGCS and the SOAP
note this will take you to “pre-encounter learner” which is a sample write-up. Once you have
viewed this sample, click Submit then you will be able to access the “post-encounter learner”
page, where you will submit your write-up.

It is best to create your write-up in a word document and then cut and paste your work into
this template on the Learning Space when you are ready to submit, rather than composing your
final write-up online. This will give you ample opportunity to proof-read your work and have
it in a readable final form without risking being “timed-out” by Learning Space!
A confirmation will be displayed stating that you have successfully submitted your assignment.

If you have any problems with the submission process see “Trouble-Shooting” below and follow
these instructions.
Trouble-Shooting:
1. CAE Learning Space® resets student passwords to their student ID numbers at the
beginning of each semester. If you do not wish to continue using your student ID
as your password, you may personalize it.
2. Learning Space will block your account after 3 unsuccessful login attempts and will
not allow you to try again for 30 minutes. Remember your instructions, above, for
resetting your password.

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IMIGCS Course Director: Dr. Tetiana Hliebova

3. Your session will be timed out after a certain period of inactivity. To avoid loss of
information from a time out error, it is advisable that you create your assignment
in a word document.

In the event that a student is not able to complete their submission in CAE Learning
Space® by the specified time due to difficulties with the technology, students may email
their submission to the email address listed below for each activity before the deadline.
These are “Drop-Box” Addresses and will document that the assignment was completed
on time.
o Semester 1 IMIGCS – IMIGCSnote@RossU.edu

Complete credit and grading of assignments for each of these activities requires
submission via CAE Learning Space®. Assignments submitted via the email address must
be uploaded into CAE Learning Space® no later than 8 pm of the following business day.
This allows the student time to contact the E-Learning Specialist
(BBRusmCAETechnicalSupport@rossu.edu ) for assistance with the technology.

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IMIGCS Course Director: Dr. Tetiana Hliebova

Appendix D: Viewing Comments on CAE Learning Space for IMIGCS

To view the comments for your ESP write-ups, click on the Reports option for the 1st
Semester IMIGCS Patient Interviews event for the date, which you attended.

On the following screen select the appropriate session from the drop down menu then Click
“Comment Report.”

Scroll to the bottom of the upcoming page where comments and write –up will be
accessible.

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