Outpatient Visit
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.
- Introduce yourself —
- Shake hands, and say “nice to meet you” or “good to see you,” etc. Patients will appreciate you for this.
- 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.
- Take vitals, or have the nurse/CMA take vitals, then document in patient file.
- Interview —
- Ask about present illnesses. Keep asking if there is anything else until there is no more.
- Ask how the patient is sleeping, eating, etc, and if everything is good at home.
- If the patient has a chronic problem, like HTN or DM2, then ask if they check their blood pressure or sugar levels regularly.
- Compare their current vitals with previous vitals and discuss any changes with patient.
- 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.
- 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).
- Advise/educate patient on any lifestyle issues, like diet, eating, or chronic issues the patient may have.
- If you don’t already have PMH, SH, FH, allergies, etc, then ask them.
- Update problem list – i.e. diabetes improved? unchanged? deteriorated?
- Update medications list – any medications the patient has stopped taking or adjusted by other doctors?
- Determine labs to order –
- 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.
- Patients taking certain drugs may need to check cpk or electrolyte levels, to monitor side effects.
- 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).
- Do Review of Systems –
- If the patient is for a normal visit, ask very briefly. Don’t go through the whole thing.
- If a patient has a specific problem, then focus the ROS on that system.
- If the patient is here for a new visit or a comprehensive physical, ask all the ROS.
- Ask about risk factors – smoking, passive smoking exposure, alcohol, caffeine use, seatbelt use, sunscreen use, amount of exercise per week, recreational drugs.
- Physical exam –
- If the patient is here for a normal visit, do a brief head-to-toe physical exam.
- If the patient has specific acute or chronic problems, like heart or some pain somewhere, then do a focused physical exam on that system.
- If the patient is here for a new visit or comprehensive physical, then do the entire physical exam. Document everything.
- A patient who is tense may need some extra reassurance, so remember to tell them exactly what you are doing.
- Document physical exam — example:
- General Appearance — alert, oriented, well-nourished, walks with cane, waddling gait, etc.
- 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.
- Cardiovascular — S1 S2 present, 2/6 systolic murmur, slight ankle swelling, normal rate and rhythm, +2 radial pulses, pitting edema on lower extremities, etc.
- Pulmonary — lungs clear, no wheezing, rhonchi, or rales, normal respiratory effort
- Abdomen — no tenderness, bowel movements present on four quadrants, slight supraumbilical tenderness, no costocervical tenderness, tympanic upon percussion, distended, etc.
- Musculoskeletal — normal range of movement, no joint swelling, pain upon 30 degree right leg elevation, etc.
- Psych — alert, oriented to person/place/time (AAOx3), intact judgement, no formal thought disorder, mood and affect appropriate, etc.
- Plan —
- Medication – order any refills, write any new prescriptions, and advise patient how to take them.
- 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.
- Referrals – make any referrals if necessary.
- Disposition – return in 3 months, 1 week, etc.
- Say good bye to patient —
- Shake their hands again, and smile. They will appreciate this.
- Say “nice to meet you again,” or “so great to see you!”
- Send them to the front desk, to pick up their paperwork, make their payments, etc.