Outpatient Visit

This is what I learned to do during my outpatient part of my internal medicine rotation. This outlines of what to do during a patient visit in the outpatient setting.

  1. Introduce yourself —
    1. Shake hands, and say “nice to meet you” or “good to see you,” etc. Patients will appreciate you for this.
    2. If a patient seems tense or in a bad mood, some small talk can go a long way in making a patient feel comfortable, like asking where they are from, etc.
  2. Take vitals, or have the nurse/CMA take vitals, then document in patient file.
  3. Interview — 
    1. Ask about present illnesses. Keep asking if there is anything else until there is no more.
    2. Ask how the patient is sleeping, eating, etc, and if everything is good at home.
    3. If the patient has a chronic problem, like HTN or DM2, then ask if they check their blood pressure or sugar levels regularly.
    4. Compare their current vitals with previous vitals and discuss any changes with patient.
    5. Ask if the patient is taking medications regularly, and if they work, and if they have any issues with them. Check to see if the patient needs any refills.
    6. Look over at labs, and see if the patient is due for any mammogram (every year after 40), or colonoscopy (every 10 years after 50, or every 5 or 3 years if abnormal findings, or every 5 years if have family history of colon cancer).
    7. Advise/educate patient on any lifestyle issues, like diet, eating, or chronic issues the patient may have.
    8. If you don’t already have PMH, SH, FH, allergies, etc, then ask them.
  4. Update problem list – i.e. diabetes improved? unchanged? deteriorated?
  5. Update medications list – any medications the patient has stopped taking or adjusted by other doctors?
  6. Determine labs to order –
    1. Generally diabetes and people with heart problems may need labs a 3-4 times per year, but if there are problems, get labs more often.
    2. Patients taking certain drugs may need to check cpk or electrolyte levels, to monitor side effects.
    3. A few labs to consider: Complete Blood Count (with or without WBC differential), Basic Metabolic Panel (electrolytes+blood glucose levels), Lipid Panel, Liver Function Tests, CPK (if patient taking statins), A1c, Mammogram, Colonoscopy, Urinalysis (these are cheap, so you could do them more often).
  7. Do Review of Systems
    1. If the patient is for a normal visit, ask very briefly. Don’t go through the whole thing.
    2. If a patient has a specific problem, then focus the ROS on that system.
    3. If the patient is here for a new visit or a comprehensive physical, ask all the ROS.
  8. Ask about risk factors – smoking, passive smoking exposure, alcohol, caffeine use, seatbelt use, sunscreen use, amount of exercise per week, recreational drugs.
  9. Physical exam –
    1. If the patient is here for a normal visit, do a brief head-to-toe physical exam.
    2. If the patient has specific acute or chronic problems, like heart or some pain somewhere, then do a focused physical exam on that system.
    3. If the patient is here for a new visit or comprehensive physical, then do the entire physical exam. Document everything.
    4. A patient who is tense may need some extra reassurance, so remember to tell them exactly what you are doing.
  10. Document physical exam — example:
    1. General Appearance — alert, oriented, well-nourished, walks with cane, waddling gait, etc.
    2. HEENT — normocephalic, atraumatic, neck supple, trachea midline, thyroid not palpable, moist mucous membrane, Mallampati II, decreased hearing, ear canals clear on right, cerumen impaction on left ear, no lymphadenopathy, conjunctiva normal, etc.
    3. Cardiovascular — S1 S2 present, 2/6 systolic murmur, slight ankle swelling, normal rate and rhythm, +2 radial pulses, pitting edema on lower extremities, etc.
    4. Pulmonary — lungs clear, no wheezing, rhonchi, or rales, normal respiratory effort
    5. Abdomen — no tenderness, bowel movements present on four quadrants, slight supraumbilical tenderness, no costocervical tenderness, tympanic upon percussion, distended, etc.
    6. Musculoskeletal — normal range of movement, no joint swelling, pain upon 30 degree right leg elevation, etc.
    7. Psych — alert, oriented to person/place/time (AAOx3), intact judgement, no formal thought disorder, mood and affect appropriate, etc.
  11. Plan —
    1. Medication – order any refills, write any new prescriptions, and advise patient how to take them.
    2. Educate — educate the patient on any new findings during the physical exam, or about any new medications you prescribe them, or just how to better self-manage themselves.
    3. Referrals – make any referrals if necessary.
    4. Disposition – return in 3 months, 1 week, etc.
  12. Say good bye to patient
    1. Shake their hands again, and smile. They will appreciate this.
    2. Say “nice to meet you again,” or “so great to see you!”
    3. Send them to the front desk, to pick up their paperwork, make their payments, etc.