CS Interview Guideline

1. Before entering:
a. Check Chief Complaint -> Make ATTACK PLAN: 2 or 3 possible diagnosis
to guide the interview. Remember vital signs.
2. Entering and starting the interview:
a. Knock, wait a second, and enter.
b. Hi, are you Mr. Smith?
c. Hello Mr. Smith, my name is Dr. Ivo and I will be the attending physician/
taking care of you today. How would you like me to address you?
d. Are you feeling comfortable in the room? Can I do anything for you to feel
better? Could I place this drape on you?
e. Start with OPEN ENDED QUESTION:
i.

I see that you came today because of _______, could you tell me
more about this?

ii. Would you like to tell me what brought you in today?

3. Chief complaint questions:
a. FORDPAPP
i.

Frequency

ii. Onset
iii. Relieving factors
iv. Duration
v. Precipitating factors
vi. Associated symptoms
vii. Previous episodes
viii.

Progression

b. PAIN:
i.

LIQOR AAA
1. Location.
2. Intensity.

CS Interview Guideline
3. Quality.
4. Onset.
5. Radiation.
6. Associated symptoms.
7. Alleviate.
8. Aggravator.
9. Previous episode.
10.Duration.
4. SUMMARIZE: Ok, Mr. Smith, I am going to make a quick summary of what you told
me: ___________, is this ok? Do you want to add anything else?
5. TRANSITION: Now, I am going to ask you some questions about your actual and
past medical history.
6. PAST MEDICAL HISTORY:

PAM HITS FOSS

a. Have you ever had this problem or anything similar before?

b. Previous illness:
i.

Have you ever been diagnosed with any illness or chronic disease?

ii. Do you have any illnesses that I should know about?

iii. Have you ever been hospitalized? Any previous surgeries?
c. Allergies ask HOW DO YOU KNOW? WHAT KIND OF REACTION DID YOU
HAVE?
i.

Medications.

ii. Other substances.

d. Medications: do you currently take any kind of medications?
e. Hospitalizations, Past surgical history
f.

Infections

g. Trauma
h. Surgical History

CS Interview Guideline
i.

Family history:
i.

Are your parents alive?

1. If not, EMPATHY: I am really sorry, I didnt want to bring up
any bad memories, but could you tell me the cause? (and
AGE)
2. If they are alive: Ask age and: Do you know if they have any
kind of illness or disease?

ii. Quickly check brothers, sons or daughters, etc

j.

OB/GYN: (LMP RTV CS PAP)

1. LMP
2. Menarche: how old were you when you had your first
period?
3. Period # of days
4. Is it regular? Do you have it every month?
5. How many tampons or pads / day
6. Cramps? PMS?
7. Do you ever have any Spotting?
8. Have you ever been Pregnant? How many times? How many
children have you had?
9. Abortions, miscarriages
10.Last PAP, was the last PAP normal?

k. Sexual History: Reassure PRIVACY and CONFIDENTIALITY of questions.

l.

I would like to reassure you that this encounter is confidential, I am

telling you this because I am going to ask you some more personal
questions.
i.

Sexual history: (SOME SSHH)

1. Are you Sexually active?
2. OCP / condoms?

CS Interview Guideline
a. It may lead to contracting various STD, like herpes,
gonorrhea or even HIV. Using condoms could prevent
the transmission of these diseases with a very high
rate of success. It is also a very effective
contraception method.
3. Male, female or both?
4. Erectile dysfunction
5. STDs?
6. Sexual function?
7. How many partners in past year?
8. HIV tested?
a. If NOT: Would you like for us to arrange an
appointment for you to get tested?
m. Social (WHARTED) ask while washing hands to save time
7. Summary: So Mr. _______ I would like to do a summary of what you've told me.
Ok Mr. _______ do you think there is anything else you may think of that might
help me help you?
a. TRANSITION TO PHYSICAL EXAM:
i.

Wash hands.

ii. Good time to ask about: (WHARTED)

1. Work
2. Home situation. Do you have any kind of family/friend
support? Any contact in the event of an emergency?
a. If NOT: here in the hospital we have a Social Service
that would gladly help you.
3. Alcohol
a. Since when?
b. How much?
c. Do you know what the risks of drinking in excess
are?

CS Interview Guideline
d. Drinking is a major risk factor for many diseases of
different organs and systems in your body, such as
liver problems (cirrhosis), cerebral problems
(dementia, depression, neuropathy), blood problems
and even cancer. Quitting early will help you lower
the risk and recover earlier and more effectively.
e. CAGE:
i.

Cut down.

ii. Annoy.
iii. Guilty.
iv. Eye opener.
v. If CAGE positive, the counseling
f.

Do you feel like quitting?

i.

YES: Great, here in the hospital we have

many different programs for you to aid you
in quitting. If you are up to it, we can make
an appointment right now for you to get
started as soon as possible.

ii. NO: It is ok, just remember that anytime

you feel ready we will be here for you.
4. Drugs:
a. Do you use drugs? What kind? Injected?
b. How much and often?
c. Do you know the risks of using ______?
d. Marijuana: SEARCH and might guide to other drugs.
e. Cocaine: heart, vasospasm.
f.

Heroin: heart, respiratory depression.

g. Have you ever tried to quit? Do you feel like

quitting?
i.

YES: Great, here in the hospital we have

many different programs for you to aid you

CS Interview Guideline
in quitting. If you are up to it, we can make
an appointment right now for you to get
started as soon as possible.
ii. NO: It is ok, just remember that anytime
you feel ready we will be here for you.
5. Tobacco: Do you smoke or use tobacco in any way?
(chewing)
a. Since when?
b. How many packages a day?
c. Do you know what the risks of smoking are?
d. Smoking is a major risk factor for many diseases of
different organs and systems in your body, such as
heart problems (atherosclerosis, heart attack), lung
problems (COPD) and even cancer. Quitting early
will help you recover earlier and more effectively.
e. Have you ever tried to quit? Do you feel like
quitting?
i.

YES: Great, here in the hospital we have

many different programs for you to aid you
in quitting. If you are up to it, we can make
an appointment right now for you to get
started as soon as possible.

ii. NO: It is ok, just remember that anytime

you feel ready we will be here for you.
6. Exercise, caffeine
8. TRANSITION: Ok Mr. Smith, now I am going to examine you. I will ask you to do
some things, so that I can examine you properly.
9. PHYSICAL EXAM:
a. I will palpate your head and neck is that ok with you? Auscultation
carotids.
b. I will untie your gown to listen to your heart, is it ok?
c. Always say: I will tap your chest, palpate your belly, check your pulses,
etc

CS Interview Guideline
d. Every time you feel the stethoscope on your back could you take a deep
breath for me please?
e. Every time you feel my hand on your back please say '99'
f.

Check CVA tenderness

g. I will now examine your pulses (4/4). Also examine skin and ask if you see
any scars: would you like to tell me why you have this scar?
h. Place table in 45* to see JVD, 'now could you lay down for me?'
i.

I will examine your belly, I wil pull your gown up a little ( pull the drape
up). (Examine McBurney, Murphy's sign, rebound, peristalitic wave)

j.

I am going to check for swelling in your legs

k. Neuro:
i.

CN II-XII: can you follow my finger with your eyes only, touch
cheeks and ask: do you feel this?, can you smile, frown, close your
eyes tightly, open your mouth and say ahh, can you stick your
tongue out? can you shrug your shoulders. THANK YOU

ii. Motor:
1. Passive motion first: could you move (injured limb) for me
please?
2. Active motion: Could you give me a hand shake? could you
pull in arm, push out arm? Now a hand shake with the other
hand, pull in arm, push out arm. Can you please Kick out
with left leg?Pull in? Now the other leg. THANK YOU. (5/5
strength)
iii. DTR: I will test your reflexes now, is that ok? (2/2)
iv. Sensory:
1. This is dull and this is sharp, can you tell me where you feel
them?
2. This is cold and this is warm, can you tell me where you
feel this? Vibration: Do you feel this? (With diapason)
v. Cerebellum: Romberg: Can you please stand up for me, put your
arms up in front of your body and close your eyes. Can you walk to
the door please? THANK YOU

CS Interview Guideline
vi. Meningeal: Brudzinski and Kernig: can you lay down please. I will
pull up your head now. Now I will pull up your legs.
l.

Always ask: Move your head towards the left, raise your right arm, etc.

10.SUMMARIZE:
b. Based on your history of _____and my physical exam findings, the source
of your (problem/ symptom / pain) can be due to (organ, ex: heart)
problems such as ______(Heart attack). Or may be due to ______ (Acid
reflux). It is crucial that we perform some tests to identify the source of
your problems. So we will start by running some blood work and
performing a _____ (EKG). Do you have any questions for me? Do you
agree with the tests?
OR
c. Based on the history and physical exam findings, it appears to me, that
you may be having problems in your (organ, system), that can be due
to_______. Or may be due to____. So it is crucial that we perform some
tests to identify the source of your problems. We will start by running
some blood work and performing a ___. Do you have any questions for me?
Do you agree with the tests?
c. Ok, perfect, so right now, my nurse is going to come and draw some blood
from you. We will meet again when I have your results back.
d. Do you have any questions? I would gladly answer whatever you want.
i.

AFTER responding: did that answer your question? Do you have any
other questions?

e. If pediatric case: Based on the history you have provided to me, it appears
to me, that your son/daughter may be having problems in their (organ,
system), that can be due to_______. Or may be due to____. It is crucial
that we perform some tests to identify the source of your daughter/son's
problems, for that I need for you to bring him/ her to the hospital. Do you
have means of transportation?
1. If parent doesn't have the means of transportation: Don't
worry Mrs.____, I will arrange for our social worker to
accompany you and bring your son/ daughter to the
hospital
11.ENDING: Reassure and leave:
a. I will be here for whatever you need me, don't hesitate to contact me.
b. Thank you very much, it was a pleasure meeting you Mr./Mrs. ______