Posted by Field from IP 18.104.22.168 on November 24, 2012 at 07:13:01:
My Dear CSA friends:
As I promised before: I would post my checklist in this forum. Now, it is the time.
Although I call it a Universal Checklist, but it can not be universal. It fits me, it may not fit you. You can
use this list just as a reference, not as a TESTBOOK checklist.
This list looks quite long than needed. But if you put a specific case into this list, lots of questions can
be omitted. Like, you do not need to ask all those Ob/Gyn Qs if the SP is a guy.
Time budget is very important, do not ask more than 40 Qs in one case (my own opnion), otherwise,
you will have time to finish the third part (Summarization, talking about D/D and work-up tests,
Education, asking if the SP has any Qs, assurance, etc), which is the easiest and most impottant part.
Cheklist is everything (I am not the first one who says this). Make your own checklist for each popular
case (headache, parkinson's disease, abd pain, arthritis, HTN, TIA, depression, PSTP, chest pain
diarrhea, vaginal bleeding, amenorrhea, blodding urine, forgetfulness, cough, sore throat, dizziness,
etc.) and practice with your CSA partner (either one the phone or face-to-face).
Good luck, my freinds.
Miss CSA? Good afternoon, I am Dr. Field. It is nice to meet you (shake hand). I'd like to ask you a few
questions and take a physical exam. So, let's get started.
History or Present Illness (HPI)
1 Mr. Smith, what brought you in today?
2 Can you describe that for me (if the pt does
not describe it above)?
3 When did it start (if the pt does describe)?
4 Did it start gradually or suddenly?
5 What were you doing just before it started?
6 Do you have any idea what might have brought
7 Please show me exactly where it is?
8 Does it move to anywhere else?
9 How does it feel like---burning, dull, sharp,
throbbing or gripping?
10 If 10 is the worst pain, where is this pain on
a scale of 1 to 10?
11 Does anything make it worse?
12 Does anything make it better?
If patient says something, just repeat (reflect) what s/he says to get a point
13 Is it constant or intermittent? If it is
14 How often does it occur? and how long does it last?
15 Is it getting better or worse or just unchanged?
16 Have you ever had a similar problem like this
before? If yes, What was the diagnosis, what
was the treatment? How did it work?
17 Do you have any other symptoms like__? __?
How about__? And __?
18 How do you treat it? How does the treatment work?
19 How does it affect your daily activities?
Okay, Miss CSA, now I need to ask you some questions about your health in general
Past Medical History (PMH)
20 Have you ever had __? __? How about __?
Any other diseases?
21 Have you had any accidents or injuries to your__?
22 Have you ever had surgery?
23 Have you ever had to stay in the hospital?
24 Are you currently taking any (other) medications?
OCP (for female)?
25 Are you allergic to any medications? Any food?
26 Miss Smith, have you had any changes in your
27 Has you had any changes in your weight recently?
28 Have you had any changes in your urinary habits?
How about bowel habits?
29 Have you noticed any changes in your sleeping
All right, now I'd like to know something about your family and find out your family's health (transition)
Family History (FH)
30 Has anyone in your family ever had a similar
31 Has anyone in your family ever had--? How about--?
32 Are your parents still living? (if one has died,
ask the cause of his/her death)
33 Anything else you would like to tell me?
Mr. CSA, now I need to ask you some questions about your family situation, your work and your lifestyle
Social History (SH)
34 Are you married?
35 Do you live a happy family life?
36 Do you have any stresses from your family
37 What type of work do you do?
38 Is your work stressful?
39 Are you exposed to any chemicals? environmental
irritants like plants, pets and animals?
40 Miss Smith, do you smoke? If yes, how many packs
per day? for how long?
41 Do you drink alcohol? If yes, how much? And for
how long? (if alcohol drinking is a major problem,
ask CAGE questions)?
a. Have you ever attempted to Cut down on your
b. Have people Annoyed you by criticizing your
c. Have you felt Guilty about your drinking?
d. Do you need an Eye-opener first in the morning
to steady your nerves?
42 Do you use any recreational drugs? do you ever
43 Do you exercise often?
44 What are your food preferences? What kind of food
you dislike? And what kind of liquid do you
Now, I need to ask you some important questions about your personal habits. Whatever you tell me will
be kept confidential (transition)
Sexual History (SexH)
45 Miss Smith, are you sexually active (if yes, ask
46 Do you use condoms?
47 Do you have one sexual partner or more than one?
48 Are your partners male, female or both?
49 Any method of contraception (for female)?
50 Have you had a STD? (If yes, what was that?
How was it treated?)
51 Have you ever been tested for HIV?
Now, I'd like to ask you some questions about your menstrual period
52 When was your last menstrual period?
53 How old were you when you had your first period?
54 Does your cycle occur regularly (every 30 days)?
55 How heavy is your blood flow (how many pads do you
use in a heavy day)?
56 How many days does your period last?
57 Do you have cramps?
58 Have you ever pregnant? How many times?
59 Have you had a miscarriage? How about an abortion?
60 When did you have the last Pap smear (a test to
check the cervical Ca)?
Thanks for answering all these questions. Now I need to take a physical examination, so I'll just wash
my hands first. Excuse me (transition)
Physical Exam (PE)
61 Okay, Miss CSA, let me begin by checking your __
62 I need to listen to your lungs. May I untie your
gown? Thank you.
63 I need to check your heart, could you lie down
please? Do you need help?
64 I'll pull out the leg extension to make it a
little more comfortable for you.
65 I am going to press in on your belly now. If it
hurts, please let me know.
66 I am going to examine your legs now, may I raise
the sheet? Thank you.
67 Miss CSA, now I am going to check the reflexes.
First, let me begin with your arms. Then, let me
check your legs.
All right, Mr. Smith, thank you so much for oyur wonderful cooperation. Now I'd like to sit down and talk
over what I think so far. First let me summarize (transition).
68 You just told me that __ and __. Also, you said
that __ and __, Is that right?
69 According to the information I got from you and
physical examination, I am considering a couple of
possibilities? It may be __ or possibly __.
70 I need to run some tests in order to find out
exactly what it is.
71 The first test I need to order is__. Then I
think___ is needed as well.
72 As soon as I study the results, let us meet again
to go over everything. At that time, I'll explain
the details and we'll talk about your options for
treatment? Does this sound OK?
73 If it is a psychiatric case, like depression,
grief, anxiety, or dementia, ask this question:
Miss CSA, would be willing to talk to a counselor
or go to a support group?
74 If Miss CSA smokes, drinks alcohol, eats fatty
food, not exercise, uses recreational drugs, has
multiple sexual partners, not use condoms, etc,
give pertinent suggestions:
Miss CSA, I have noticed that you__, are you
willing to stop doing it?. If you need any more
help from me, just let me know. I'll be glad to
75 Miss CSA, do you have any concerns or questions
you'd like to ask before I go?
76 Well then, I am very grateful that I could be able
to work with you. Miss Smith, thank you for
coming in. I want to assure you that I'll be very
careful and thorough in helping you. (Shake hand
77 Bye for now, take care.
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