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Alrighty, step-by-step how-tos for ND medical students from a ND medical student, 
one - the H&P:
1. Knock, introduce yourself, say who you're working with and ask if it's okay if you speak with them first before their doctor comes in. If not - it's okay! I've never had this
one - the H&P:1. Knock, introduce yourself, say who you're working with and ask if it's okay if you speak with them first before their doctor comes in. If not - it's okay! I've never had this
happen but consent matters so just say no problem, leave the room, tell your preceptor.
2. Clean your hands and verify their name (and pronouns if you plan on using them)
3. Sitting down puts you at eye level with patients, so if you're comfy with eye contact, it makes them more
2. Clean your hands and verify their name (and pronouns if you plan on using them)
3. Sitting down puts you at eye level with patients, so if you're comfy with eye contact, it makes them more
comfortable. I personally prefer to immediately sit down. In OSCEs they may have you ask SPs "may I sit?" which never feels right in real encounters, to me.
4. Ask what brings them in today. If you have a CC, you can say "I see you wanted to talk about x, is that your main
4. Ask what brings them in today. If you have a CC, you can say "I see you wanted to talk about x, is that your main
concern?" It might not be, especially if the real concern is embarrassing or hard to explain to the schedulers on the phone.
5. If I ask people how they're doing/feeling, and they look a little hesitant, I'll throw in a "probably not great because you're here with us/you're sick,
5. If I ask people how they're doing/feeling, and they look a little hesitant, I'll throw in a "probably not great because you're here with us/you're sick,
huh" before they can instinctively say "fine" after the pause. It lightens the mood and gives them permission to share how they're ACTUALLY feeling with you. They might laugh a little and then explain what's going on. Or they'll clarify that no, they really are fine, BUT...
6. Once you've identified why they're here, you can ask more about the problem. The OPQRST mnemonic is one a lot of people use. How long has it been happening? What makes it worse or better? Have you tried x thing? Describe the pain/symptom? Does it go away or is it constant? etc
7. Then you move into "pertinent positives and negatives". This part can be hard until you gain experience with lots of different diseases and how they present, and what would make you think one vs. another. If you miss things initially, don't feel bad. You're learning. So for
example, if someone comes in with lower right quadrant abdominal pain, you don't need to ask ROS questions for every single body part. You would start out with things like nausea, vomiting, fever, stool changes, do they still have their appendix, do they have ovaries/testes,
has this happened before, did bumps on the car ride over make the pain worse, is this associated with certain foods? You would then add things like dysuria/urinary urgency/lifting or trauma. In your brain each question should be related to something it *could be* so you get a
better idea of which it actually is.
8. If you don't already have this information or need to clarify it, you'll ask about
-Past medical history (diseases they have or have had)
-Surgical history (also ask about trauma/accidents, procedures, hospitalizations, not just surgeries)
8. If you don't already have this information or need to clarify it, you'll ask about
-Past medical history (diseases they have or have had)
-Surgical history (also ask about trauma/accidents, procedures, hospitalizations, not just surgeries)
-Family history (first degree relatives typically matter most, so mom/dad/siblings/grandparents)
-Social history (tobacco, alcohol, other drugs, sexual history, diet/exercise, home situation/support system, abuse, barriers to care - this one is big and tailored to the specialty)
-Social history (tobacco, alcohol, other drugs, sexual history, diet/exercise, home situation/support system, abuse, barriers to care - this one is big and tailored to the specialty)
-Meds (including OTC and "natural"/homeopathic/supplements, ask about route and dose and frequency)
-Allergies (drug and food and WHAT THE REACTION IS)
9. The history may be way longer or way shorter depending on where you're at. Surgical? Very short. IM or family? Often very
-Allergies (drug and food and WHAT THE REACTION IS)
9. The history may be way longer or way shorter depending on where you're at. Surgical? Very short. IM or family? Often very
comprehensive. But the amount of time you have for a visit means you may need to cut chunks out or ask about these things way more speedily than feels reasonable.
10. If someone has more than one problem and you have very limited time, ask which is most important to them to
10. If someone has more than one problem and you have very limited time, ask which is most important to them to
address right now. You might have to adjust for acuity, like "We may actually need to focus on the chest pain, because that can be more dangerous than your toenail fungus, but we'll do our best to take care of both. You can always come back for another visit to handle more
problems." This is really hard to say for someone who is poor or has navigated impossible healthcare systems before, because you know that they have a bulleted list for a reason. But as a student, you also have no control over appointment length and just have to do your best with
what you have.
11. With very talkative or long-winded patients, you'll need to practice redirecting and interrupting with questions. This is super uncomfortable and will take a lot of work to perfect. "So what I'm hearing is x, are you experiencing y?" or "I love that you're so
11. With very talkative or long-winded patients, you'll need to practice redirecting and interrupting with questions. This is super uncomfortable and will take a lot of work to perfect. "So what I'm hearing is x, are you experiencing y?" or "I love that you're so
attentive to your kids - they sound wonderful. I want to get you taken care of, though, so let's focus on *symptom* you mentioned for now."
12. The physical - Ask. For. Consent. This doesn't have to be weird. You can just say "I'd like to take a look and listen to your heart/
12. The physical - Ask. For. Consent. This doesn't have to be weird. You can just say "I'd like to take a look and listen to your heart/
lungs/*whatever*, is that alright?" Or "I need to push on your belly now, so we can get a better idea of what's going on. It might hurt (or it might not!) but it will give me important information about why this might be happening. Is that okay?" Don't lie about things not
hurting when they probably will. Don't just touch people without explaining what you're doing and being sure they're on board. If anyone knows all this it's probably ND people but it's just good to keep in mind because this is part of trauma-informed care.
13. If you're doing a
13. If you're doing a
full physical, have a system, like head to toe, or least to most distressing/accessible. Especially with kids - do ENT last because it stresses them out, and if they're crying then yay! you can see their mouth well.
14. If you're doing a focused exam, cover the relevant systems
14. If you're doing a focused exam, cover the relevant systems
with specific exams, and be observant about the rest. For abdominal pain you don't necessarily need to do a full eye or neuro exam. You can document EOMI if you observed that their extraocular muscles are indeed intact by watching while interviewing, even if you didn't make them
follow your finger with their eyes. You can say whether they move all extremities spontaneously, whether they ambulate unassisted or with *mobility aid*, whether there are gait changes, whether there are any visible rashes/bruising/discoloration, etc. just by looking. Note
under "general" whether they appear to be distressed or in pain or look acutely ill.
15. Listen to heart and lungs no matter what they're there for. If they have an abdomen problem, though, you better auscultate and palpate it. If they have a knee problem - touch that knee.
15. Listen to heart and lungs no matter what they're there for. If they have an abdomen problem, though, you better auscultate and palpate it. If they have a knee problem - touch that knee.
Look at, listen to, palpate, and provocatively test whatever body part the problem is in, even if you think you know what's going on without doing so. It's easy to forget bits of the physical exam when you're constantly being rushed but you WILL be asked about findings.
I'll give some examples of "what can you just observe" physical exam findings in a bit. And will prob write about doing notes/presentations. A lot of this is stuff I had to ask about specifically or find out the hard way because it 
isn't clear #MedStudentTwitter
isn't clear #MedStudentTwitter
