Opening of the case

(Knock on the door, enter, smile if appropriated). Mr… ? Good morning, I’m Dr…. , I am an attending physician in this hospital. Nice to meet you. (Shake hand). Today I will take care of you.

First I will ask you few question and do brief physical examination. Meanwhile if you have any questions, feel free to ask me. Is that OK? Let me make you comfortable. (drape patient at this time). Is there anything else I can do to make you more comfortable??

Just to make sure that I don’t miss any important information, do you mind if I take some notes while we talk? Thank you

Please tell me what brought you in today? open ended question. listen to patient carefully and don’t interrupt the patient.

I am so sorry to hear that. (Empathy) Start asking (OS PDF LIQRAA + -)

Then Mr…. I’d like to ask you few  question about your general health (ROS). (THEN FR CS PUB SAWED), Remember This is just a check list, don’t write anything.

Mr…. Now I’d like to ask u few question about your health in past, is that OK? (PAM HITS FOS SAW)

Mr…. Thank you. I am done with history, Let me summarize it for you…. is that correct? Is there anything else you would like to share with me? Do you have any question for me at this time?

Now I need to examine you. May I proceed? But let me wash my hand first !! Is it OK?

(One you are done with examine patient) Mr… Thank you for your cooperation. I am done with physical exam. Let me give my impression. Based on your history and my physical exam, it seems that you might have …. but it could be something else/ … or …., in order to arrive at right diagnosis, I like to run some test, such as blood test, urine test, and also order some imaging studies such as x-ray, CT scan. once I’ve result, We will meet again to discuss them and once we know final diagnosis we work as a team to plan the next steps. Is this sound good?

Do you have any question or concerns?

I understand your concern…. did that answer your question?

Okay, Mr…, I’ll will contact you when I have your test results. It was pleasure meeting you, Shake hand and leave the room.

In case of short of time. oh Mr… we have an emergency and I have to leave, I will see you soon as I get free. shake hand and leave room.