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PACS

PACS. Patient Interview. Name? Age? Date? Place ? CC : What brings you in today? – quote their words HPI : O – onset – when started/anything triggered it? P – position/pattern – with one finger show exactly where? Q – quality – what kind of pain is it? R – radiation

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PACS

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  1. PACS

  2. Patient Interview Name? Age? Date? Place? CC: What brings you in today? – quote their words HPI: O – onset – when started/anything triggered it? P – position/pattern – with one finger show exactly where? Q – quality – what kind of pain is it? R – radiation S – severity (1-10) – if you had to put a # to it…. T – timing: what makes better/worse – time of day? Taking/doing anything for it? ROS: fever, chills, night sweats, recent weight loss/gain? Med Hx: Other conditions? Trauma? Allergies? – specific reaction Medications? – prescription, OTC, vitamins, contraceptives Childhood diseases? – immunizations SurgHx: Surgeries – dates, types FamHx: HTN, cancer, diabetes Soc Hx: Tobacco: pack years = # packs per day x # yrs Alcohol, Street drugs, Occupation, Lives alone/marriage/ signifother/family

  3. Physical Exam Vitals:BP P RR T Heart: - Fingernails (color + splinter hemorrhages) + LEs (edema) - JVD (jugular vein distention): Central venous pressure (7-9cm norm) - Carotid pulse: palpation (one side at a time) and auscultation • Auscultation: Always Pay The Man • PMI (point of maximal impulse): heart size, placement • Friction rub: to differentiate from lungs Lungs:Auscultatefew posts OMM: Red reflex “ Anything else you can think of for this complaint?” “I’m going to speak with my attending now…”

  4. Camera and Finishing up -“Mr. Smith is an 80 yr old white malepresented today with CC + OPQRST” For Example: Mr. Smith is an 80yr old WM presenting today with 7/10 chest pain that radiates down his left arm. The pain stared 1 wk ago and only occurs on exertion. Pain is relieved with rest. Patient has taken nothing for the pain. -Summarize Hx and findings of the PE: just mention the important stuff like HTN, hyperlipidemia, smoking, medications… -“My assessment of this Pt is suggestive of…”DDx: MI, GERD, Angina, Percarditis, PE -“I would like to send Pt for …. lab tests/imaging/treatments”: Aspirin, EKG, CXR, CBC, electrolytes, CPR-MB, troponin, ECHO, cardiac catheterization -“I would like to counsel Pt about… tobacco (alcohol) cessation program/ exercise program/ etc.” - “Will set up follow up once results come in/ in a few days/ etc.” Back to Pt: -” We think you have ….” - Plan – “These are the tests we will run to rule out…” - F/U – “We will call you once results come in” - “Any questions?”

  5. SOAP Note S – CC:“Chest Pain” HPI:Mr Smithis an 80 yr old WM presented today with … OPQRST. Med Hx: SurgHx: FamHx: ROS: No fever, chills, nausea, weight loss/gain. O– Vitals: BP P RR T General: Pt is in no/slight/significant distress. Otherwise appears in good health. AAO x3. Lungs: Equal B/L chest rise. Clear to auscultate B/L (CTA(B)). No wheezes, rales, rhonchi.Negegophany, bronchophony. No use of accessory muscles. CVS: Regular rate & rhythm (RRR). No murmurs, rubs, gallops (neg M/R/G). AP diameter within normal limits (WNL). Neg PMI. Neg Friction rub. JVD WNL. No notable edema. OMM: Negative red reflex. A/P– 1) State what Pt has (CC in “doctor speak”). DDx - ………………….. - Plan: tests & treatments - images, culture, labs, OMT, additional meds, etc. DDx- ……………………. – Plan: DDx - ……………………. – Plan: DDx – Somatic Dysfunction - OMT 2) State another problem you may have discovered (e.g. ETOH or tobacco abuse) Plan: “Counsel Pt to stop”. Signature/Name/OMSI/Date

  6. Lastly… • Patient visits – 20min • SOAP note – 15 min • Critique • Dress code, instruments • $ 5 • Problems: • Dr. E’s OMM review on Thursday • Additional time-slots??

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