Suggestions for the Outpatient Visit

New patients/annual “check-ups”

The structure of the new patient visit will vary in general and subspecialty clinics. Overall, you should collect an HPI if the patient has a chief complaint. If not, collect a past medical, surgical, gynecological, and psychiatric history as appropriate; inquire about medications, drug allergies, family history, and preventive health. The latter is of particular importance in the primary care clinic. You should ask about vaccination status, screening, vitamins, and alternative therapies.

Follow-up clinic visits

Outpatients frequently do not have a chief complaintthey frequently have multiple complaints or multiple medical issues. As follow-up clinic visits are generally brief, one may not be able to cover all the patient’s concerns in one visit. Your job is to set an agenda with the patient that covers his or her most significant concerns as well as yours.

 

What follows is a suggested structure for the outpatient interview:
1. Prepare: Find out what the patient’s medical problems are by reviewing their chart or discussing their history with their physician.

2. Negotiate an agenda:
a. Ask the patient what his or her concerns are.
b. Prioritize problems that are most concerning to you and to the patient.
c. Negotiate the agenda of the visit; this may involve establishing the status of chronic medical problems or age-appropriate screening for illness.
d. When the patient has more concerns than can be covered, let the patient know that you would like to hear more about those concerns during their next visit.

3. Gather the data:
a. Conduct a focused history with targeted review of systems. For example, in a patient with diabetes, you may want to ask about polyuria and polydipsia.
b. Perform a targeted yet appropriately thorough physical exam.

4. Collect your thoughts:
a. What are the major issues?
b. What are the most likely differential diagnoses?
c. Do you have time to quickly read up on your patient’s complaint?
d. What is your plan for diagnosis? For treatment?

5. Present the case:
a. Identify the patient: “Mr. Smith is a 50-year-old man with hypertension and diabetes who presents for a routine three month follow-up.”
b. Review the agenda: “In addition to reviewing his chronic medical problems, the patient also wanted to discuss left knee pain.”
c. Present the problem list:
i. Knee pain: “The patient has had knee pain for 6 months. It is worsened by …”
ii. Diabetes: home blood sugars average, lowest reading was, highest reading…last eye exam was…foot care, etc.
iii. Hypertension.
iv. Health maintenance.
d. Present the physical examination.
e. Present your assessment: “Overall, Mr. Smith is doing well. His diabetes and hypertension are adequately controlled. The differential diagnosis for his knee pain is osteoarthritis, gout, and pseudogout. I think it is most likely…”
f. Present your plan:
i. For his knee pain, X-rays will help to confirm the diagnosis of OA. He can try Tylenol for the pain. We should avoid NSAIDS in diabetic patients if possible.
ii. For his diabetes, check hemoglobin A1c…etc.
iii. For his hypertension…
iv. For his health maintenance…
g. Discuss follow-up appointments and referrals.

6. Alternative case presentation: “problem-based”:
a. Identify the patient: “Mr. Smith is a 50-year-old man with hypertension and diabetes who presents for a routine three month follow-up.”
b. Review the agenda: “In addition to reviewing his chronic medical problems, the patient also wanted to discuss left knee pain.”
c. Present each problem with subjective, objective, assessment and plan
Problem 1: Knee pain
S: notes lateral knee pain, worse with going downstairs and on flexion. No give-way or locking. No swelling
O: L knee tender to palpation over lateral joint line. No swelling or erythema. Full ROM. No instability. Negative varus and valgus stress. Negative McMurray’s
A: Differential diagnosis includes OA, lateral meniscal or lateral collateral ligament injury
P: Trial of acetaminophen for pain. Trial of physical therapy.
Problem 2: Diabetes
S: denies polyuria, nocturia. Using 20 units of glargine every night. No hypoglycemic reactions. Avoiding simple sugars. Tests fasting sugars every morning and reports 90-120
O: Last A1C 9.2, microalbumen WNL
A: Not well controlled. May need prandial rapid-acting insulin
P: Begin testing 1 hour post-prandial blood sugars

7. Follow through: check test results and communicate these with the patient as arranged with your preceptor. Your patients will be expected to call you to notify you of upcoming tests, procedures, or specialty consults. You should make every effort to attend these, but should not miss other specialty clinic sessions to do so.