STATION #

J.D.

PLEASE CONDUCT FOCUSED HISTORY AND COUNSEL AS YOU WOULD IN PRACTICE.

INSTRUCTIONS

1 - YOU HAVE 8 MINUTES TO COMPLETE THE STATION 2 - WARNING WILL NOT BE GIVEN 3 - THERE WILL BE POST ENCOUNTER QUESTIONS

MY ACTUAL 2 MINUTES NOTES:

ACTUAL ENCOUNTER: Patient cues: POST ENCOUNTER QUESTIONS: FEEDBACK COMMENTS:

POSSIBLE APPROACH:
Possible Differentials I should think about while waiting for 2 minutes: Vascular: Infectious: Trauma: Autoimmune: Metabolic: Idiopathic/Iatrogenic: Neoplastic: Substance abuse and psychiatric: Congenital:

INTRODUCTION: Hello. (First Name) (Last Name)? I am First of all, (how may I call you?) (may I call you (First Name)? Thank you, (First Name). I would like to begin by asking you some questions (and later on do a physical exam) so I could determine what needs to be done. CHIEF COMPLAINT: So, (First Name), what brings you in today? COUGH, FEVER & RAPID BREATHING HISTORY OF PRESENT ILLNESS: Focus on Chief Complaint

Character

Can you describe the cough? Is it like clearing the throat? Barking? Hacking? Whooping? Any sputum production? Color and how much? (Mucus, blood, pus) (Where was the patient when it started? Were you away on a trip?) How did it start? Was it sudden?

Location Onset Radiation Intensity -

How severe is it? Any particular time of day? Any difficulty of breathing? Have you taken his temperature? Duration How long has it been going on? Is it getting worse? Events associated Any noisy breathing? Any exposure to irritants? Any contacts with sick person, day-care, school? Any sore throat, runny nose, ear pain or headache? Chest pain? Crying? Frequency Has this happened before? When? How often? Palliative factors Is there anything that makes it better? Provocative factors Is there anything that makes it worse? Previous investigations Past medical/surgical history Asthma? Any previous hospitalization/surgery? Medications What medications are you giving him? Allergies Any known allergy? Social history Usual diet? Smokers in the home, pets, carpets, dust? Family history Asthma, allergies, eczema, rhinitis, CF or -antitrypsin deficiency? STANDARD Qs: (Now, I would like to ask questions that I usually ask all my other patients/parents) (Determine if age/case appropriate) PRENATAL: Did you have prenatal care? Any difficulties during the pregnancy? Any complications during it? High blood pressure, Anemia, diabetes, infection? Explore: What? How was it treated? Did you use alcohol or recreational drugs during the pregnancy? Did you smoke during the pregnancy? Was it a single pregnancy or multiple? NATAL:

When was your delivery? Was it a term pregnancy? What was the method of delivery? (If, induced) Why? How long did it take? Any complications during labor like prolonged labor, ruptured water bag, fever? NEONATAL: How was he/she at birth? (APGAR SCORE) How much was his/her weight? Any abnormalities or complications like being yellow or blue, feverish, or didnt cry immediately? Explore: What/ When/ How long? (Empathy for healthy/ unhealthy pregnancy.) Any problems as a baby? Any hospital admissions? IMMUNIZATION HX: What needles has been done so far? Does he/she have? (age appropriate immunization) NUTRITION/ OUTPUT: Tell me about his/her feeding/eating habits? Is he/she on breast or bottle feeding? How much do you give him/her each time? How many times in a day? Any solids, vitamins, iron, supplements? What? When did you start? Is it balanced diet? Any junk food? Any difficulty sucking/ swallowing? Is he/she a picky eater? Tell me about the feeding setting & facilitation? OUTPUT (BLADDER/ BOWEL MOTIONS): How many times a day dose he/she pass water? How much each time? (Or How many wet diapers day?) Smelly urine? Red urine? How many times a day does he/she have a bowel motion? How much each time? Is it formed or loose? Smelling stool? Blood? Mucus? What color is it? Green/ yellow/ white cheesy? Explore. Does he/she control his/her bladder & bowel? (for >4 years old) DEVELOPMENT: Any delay in speech, language, or motor development? Physical: What is his/her height and weight now?

Milestones Is he/she able to.. ? (Gross motor, Fine motor, Speech, Social)Age appropriate now only, no need for previous. Social/ School performance: How is his temper? Is he irritable, crying frequently? What about sleep? Does he/she attend school? What grade? Any problems at school? Any failures or suspensions? What is his/her daily routine? ENVIRONMENT: Are there similar problems with relatives, at daycare, at school? Who is usually taking care of him/her? How are the family relationships? How has this been affecting the family? Do you feel your mood low? Any lost workdays? How are you managing with the expenses? DIFFERENTIAL DIAGNOSIS: Croup, viral Bacterial tracheitits Epiglottitis Anaphylaxis INVESTIGATIONS: PE CXR MANAGEMENT: Humidified O Dexamethasone: PO 1 dose Racemic epinephrine: nebulized, 1-3 doses, q1-2 hours Intubation if unresponsive to treatment