PESCI STRUCTURE

Scenario

Overview – Red Flags

DDx

History Taking

A. Biological history

1-SGC PCO

• Stability, wellness:

o Where is my patient?

o Is he/she stable or not?

o 3P, 2C, 1B (PAT for children)

▪ Pallor, Pain (chest pain – any severe pain), Protective posture

▪ Cyanosis, Any Consciousness changes?

▪ Any Breathing Problem

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Observe child : if he is well or unwell

Use a modified ABCDN to help triage whether well or unwell:

• A – Alertness – mental state such as activity, interaction, vocalisation,

consolability

• B – Breathing – observe respiratory effort for tachypnoea, grunting, upper

airway noises

• C – Colour (circulation), whether mottled, pale

• D – Dehydration – listless, dry mucous membranes

• N – Neurologic signs – Bulging fontanel, Depressed fontanel - Disabled or

discomfort due to pain

o DRSABCD if due (Go to Emergency structure)

• Greeting/ Introducing- Ethnicity – Language barrier

o Use simple words – be culturally sensitive (aboriginals) and have friendly manner

▪ Greeting is different in new cases or regular cases

▪ Offer TIS national (translating and interpreting system)

• Chief Complaint - Empathy

o Ask the patient to describe their problem; What’s brought you here today?

o Empathy and reassurance

▪ We would work on it together or I will do my best to help you on any

aspects, I can.

• Offer Pain killer: Are you in Pain right now?

▪ Immediately

▪ I would give something to you for your pain just after letting me know more
about your problem (or just after a while)

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▪ if needed, always check 2 items before giving pain killer:

✓ Any sensitivity or contraindication to that pain killer

✓ Any previous pain killer (which medication? when?)

• Consider Confidentiality - privacy and normalization

Ok, I would like to have a friendly chat about this problem, see what is going on and what I
can do for you. Everything between us will remain confidential. Is that ok for you?
For me, as your GP, to better help you and choose the best option, it is better to have more
information about your well-being, and because of that, I usually need to ask some questions
from all patients. Is that ok with you?

• Open-ended questions : Can you explain it more for me?

2-SOCRAT1

• Site and Severity

o Can you tell me exactly where the pain is?

o How would you rate it on a scale of 0 to10? Better question: How bad is it from 0 to
10?

• Onset

o When did it start?

o How did it start? Gradually or abruptly

o Was it continuous? Or time to time (intermittently)?

▪ Continuous: Can you describe the pattern? Was it worsening or not? Is

there any change in the characteristic or the intensity?)

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▪ Intermittent: How often did you have it a day/week/…?

▪ How long did it last?

o Triggers: Can you remember anything particular that brings it out?

▪ What were you doing exactly when it started?

• Character

o Could you describe this pain? Burning? Tingling? Tightening? Colicky? Sharp?
Throbbing? …

o Is there any diurnal pattern?

• Radiation: Does it travel anywhere else?

• Alleviating and exacerbating factors?

o Is there anything that makes it better or worse?

• T1: Have you ever had anything like this before?

If yes:

o have you been visited by a GP?

o Did you take any medication for that?

o Did it work?

3- ICE & EFFECTS (Ideas, Concerns, Expectations)

Level of understanding about problem

• Idea: What do you think is causing the problem?

• Concern: what is your main concern about this problem?

• Expectations: What do you expect me to do for you at this session?

• Effects: How did it affect your daily routine? (Sleep, work, school, job, relationship, activity,
hobby)

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• Do you have any other concern you want to share with me? (hidden agenda)

Time to Summarize the problem list

4- FOLLOW-UP SESSION : REPRESCIPTION OR LAB TEST INTERPRETATION

Represcription

➢ Medication

o Check RATES

▪ Risk of interaction (with other medications or diseases)

▪ Adherence (if negative why? Is it because of side effects or financial

problems, Forgetting)?

▪ Toleration: consider dose balance

▪ Efficacy

▪ Side effects

➢ Primary problem (before starting medication)

➢ During the treatment

▪ Any change in dosage?

▪ Last visit?

➢ Present Problem

➢ Consider if there is any reason to continue or not

➢ Always check technics in 1- Asthma puffers 2- COPD puffers 3- Insulin

➢ Check if there is any action plan or not? (if due)

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LAB tests interpretation

➢ Interpret Lab tests and diseases by detail in simple world. You can directly go
through lab tests if the patient wants, or ask him/her to have a friendly chat about
his/her well-being before.

➢ Is there anything else you would like to discuss with me as well?

➢ Just remind me, why did you do the test?

➢ Confidentiality

➢ Interpret the results

➢ Ask about previous results

Don’t say Abnormal and Unfortunately… better way: It is not something as we expected! Or
out of normal range

5- ASSOCIATED SYMPTOMS

Let’s talk about some important symptoms? Do you have any other physical symptoms like:

6- WELLBEING QUESTIONS (‫)خواب و خوراک‬

• Diet

• Sleep pattern – snoring (if positive, ask about morning headache, sleepiness)

• Water work (WW)

• Bowel motion (BM)

7- CONSTITUTIONAL SYMPTOMS

• Any Chills or Fever?

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• Any fatigue?

• Any changes in your Appetite?

• Any loss of weight?

• Any Night Sweating?

• Any Lumps of Bumps anywhere on your body?

8- PAST MEDICAL HISTORY(ADULTS): MMAHI

Clue: Thank you …. Regarding your past medical history, may I know if you have been ever diagnosed
with any medical condition or any specific diseases in the past? I want to ask some questions about your
past medical history, How do you feel about that? or is that ok with you?

• Medical condition or disease (Any medication? Ask: Adherence, side effects, efficacy)

• Medications: Prescriptions, OTCs, herbal?

• Allergy

• Hospitalization

• Immunization

8’- PAST MEDICAL HISTORY (PAEDIATRICS): BIND PP AV

• Birth - before & after: Any problems during pregnancy, labor or after birth? Full term or not?
Uneventful birth or pregnancy? Full term or not? Antenatal tests?

• Immunization – Is the child vaccination up to date?

• Nutrition – How is his/her feeding? Is he/she bottle feed or breast feed?

• Development and growth and behaviors - Are you happy with his/her growth?

o When could he/she count the numbers? When did he walk independently? When
could he talk?

• Poo

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• Pee

• Audio – Any problem with hearing?

• Video – Any problem with vision?

9- HEALTH CHECK (SCREENING)

Mammography, FOBT, CVD risk assessment and …

10- FAMILY HISTORY

Clue: I want to ask you some questions about your family medical history? Is that ok with you?

• Is there a specific medical condition running in your family members?

• Is there anyone around you (or among your family members) suffering from the same
disease?

• Is there a specific medical condition running in your family members?

• Number of siblings, children …

• Father and mother: Are your parents healthy and alive? (If no: Why- empathy)

11- SEXUAL HISTORY

Clue: I am going to ask you a few questions regarding your sexual life? Is that ok with you?

For men: AIPPP

• Sexual Activity

• Last Intercourse

• Partner: Are you in a stable relationship? If not: do you have any casual partner?

• Any Problem (Ejaculation, Erectile dysfunction or…)

• Any Past history of STI

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For Women: 6Ps – B

• Period:

o LMP

o Regularity – duration (cycle, bleeding) - how long does it last?

o Volume: how many pads/tampons during the day? Any night bleeding? Any clot
(size, frequency)? Soak your clothes? Does it affect your daily routine?

o Pain: Any Painful bleeding? Any PBS (Pain – bleeding – spotting) between periods?

o Menarch age

• Partner

o Sexually active?

o Have you had any new partner during the last 3 months?

o Have you had more than one partner during this year?

o is your partner supportive? (violence)

o When was your last intercourse? (if due)

o After intercourse: PBS?

o When was your last unprotected sex?

o Sex preference (male, female, both)

o Route of sex (vaginal, Anal, oral)

• Pregnancy

o Is there any chance that you might be pregnant right now?

▪ PBS in pregnancy if she is pregnant?

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o Have you ever had any positive pregnancy test? How many times?

▪ If yes, was it uneventful?

▪ Any problem with your pregnancy?

▪ What was the method of delivery?

o Do you have any plan for child bearing?

• PID – STD

o Have you or your partner ever been diagnosed or treated for any kind of Sexual
transmitted disease?

o Any Symptom? (Any itching, any discharge, any skin change down below?)

▪ STI risk is increased if the patient:

• is aged < 30 years.

• self-identifies as being at risk i.e., asks for a sexual health check.

• has had a new sexual partner in the last 3 months.

• has had > 1 sexual partner in the past year.

• had another sexually transmitted infection (STI) in the past 12 months.

• has a sexual partner with an STI or symptoms of an STI.

• had recent intrauterine instrumentation e.g. termination of pregnancy

(TOP), intrauterine device (IUD) insertion.

• Pill: can I ask you about your birth control method?

o Now and before

o Any side effects?

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• Pap test (CST) and HPV Screening

o When was the last time that you have been checked for any disorder of your cervical
screening test? (don’t say “neck of womb”)

• Breasts: (Ask about nipple changes – breast tissue – skin changes)

o Do you have any problem with your breasts?

o Any lumps, tenderness, discharge, skin change?

o Any Pain?

o Any Warmness?

IMPORTANT: PBS: Pain Bleeding Spotting:

Ask in 4 situations: 1-between periods 2-after intercourse 3-pregnancy 4-menopause

B. Psychosocial history

Clue: if that is ok with you Mary, I am going to ask you few questions regarding your social life as well

Or : Moving to your social history if that is ok with you…

12- SOCIAL HISTORY: HOT SAD LIFE STYLE

• Home:

✓ How is everything at home?

✓ Whom do you live with?

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✓ Is your partner supportive?

✓ Ask about pets…

• Occupation – Education - school –

✓ How`s everything at work? how is everything at school?

✓ Have you taken some days being off work recently?

✓ Ask about bully and abuse

✓ Any financial issue

• Travel

• Smoking

• Alcohol

• Drug: Some patients do drugs to feel better. Do you think this may be related to you in any
case?

• Life style: activity – hobby – driving

13- SOCIAL HISTORY ADOLESCENCES: HEADSS

• Home & Environment

o Bullying: Working with youth I have learned from some “kids” that their relationship
with their parents is a difficult one; by this I mean they argue and fight. Some youth
have told me that they wish their parents did not drink so much or use drugs. Is this a
situation in your household? Has anything like it happened to you?

o Have you experienced any bullying at home?

• Education & Employment adolescences

o What were your most recent grades? Are these the same or different from the past?
Have you ever failed or repeated any years?

• Activities

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o What do you do for fun?

o What things do you do with friends?

o What do you do with your free time?

• Drugs

o Many young people experiment with drugs, alcohol, or cigarettes. Have you or your
friends ever tried them? What have your tried?

• Sexuality/Suicide/Depression

o Have you ever been in a relationship? When? How was it? How long did it last?

o Have you had sex? Was it a good experience? Are you comfortable with sexual
activity? Number of partners?

o Using contraception? Type and how often (10, 50, or 70% of the time).

14- PSYCHIATRIC HISTORY: MSIAGECAPS PS

First ask screening questions:

• Mood

• Anhedonia

• Stress

• Anxiety

If any positive result then ask MSIAGECAPS PS

DSM V for depression

Changing in mood OR anhedonia + 4 symptoms of these:

• Mood: During these two weeks have you felt down, depressed or hopeless? Any
history of elevated mood?

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o Any feeling anxious? Exccesive stress?

• Suicide: I need to ask you because it is my job to make sure you are safe –

o sometimes people with depression or low mood think that it is not worth living.
during this .... have you ever felt like that?

o have you had any thoughts of harming yourself or anyone else?

o If yes: Do you have a plan about how you would do this?

o Do you have access to anything you could use to carry out your plan?

o Have you made any preparations?

o Have you done something to harm yourself before?

• Insight (not in DSM V, just remember to evaluate insight

• Anhedonia: During these two weeks have you had little interest or pleasure in doing
things?

• Guilty – worthlessness

• Energy – fatigue: Are you feeling excessively tired? / or Overly energized?

• Concentration

• Appetite change – weight change

• Physical activity – work and social (functional impairment : work) and Psychomotor agitation
or retardation (restlessness or slow down)

• Sleep

For Mania ask:

• Excessive Powerful: Do you sometimes feel excessively powerful as though you could do
anything?

• Excessive Spending: gambling – spend more money recently

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A- RULES OF 7 (ELDERLY PATIENTS >60): MEMEM BL / IN HISTORY AND EXAM PART

Mental State (MMSE): In QUESTIONNAIRE part

Eye

Mouth

Ears

Medications – Polypharmacy – Side effects

Bowel and Bladder

Locomotion: Gait – arthritis – feet - nail – leg ulcers

B- Assess risk of fall in elderly patients >60

1- falling history

2- Muscle weakness

3- feeling imbalance

4- vision problem

5- sedative medications

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Examination
IMPORTANT IN CHILDREN: Dehydration (not all cases) – interaction and relation
with parents – Growth chart – Signs of non-accidental injuries

Phase 1

For children:

o I usually try to explain what I am going to do in examination and ask the child
to interrupt me whenever he feels uncomfortable or pain.

o Giving toy

• Explanation of all stage of examination to my patient

• Obtaining Consent, ensure that patient is comfortable

• Offering chaperon (if needed) - Offer same Gender GP (for aboriginals)

• Washing hands (before and after) and helping the patient to get ready and appropriate
exposure

• Providing complete privacy for my patient and Providing a gown and sheet to have a proper
position and adequate exposure

• For Gynaecological examination (if due): Ask patient to empty her bladder and give urine
sample for office tests

Phase 2

• For children:

o I try to check whether the child looks well or unwell, has any distress and
discomfort or any pallor, level of self-hygiene and facial expression.

o I need to pay attention to the relationship between mother and child during my
consultation and examination

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• General Appearance

(Always in delirium, diarrhea, Bleeding, Fever: Check hydration Status)

o Mucosal dryness, decreased skin turgor, sunken eyes

• V/S

• BMI – plotting on growth chart (children)

• Waist circumference +/-

• O2 Saturation (If needed)

Phase 3

Always tell your outline of the examination! And tell the panel a brief reason for each
examination

• Focused examination

• Relevant examination

Phase 4: Any Relevant Questionnaire

Phase 5: Office Tests

• ECG

• BSL

• Spirometry

• Urine dipstick

• Pregnancy test

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Management
1- Clinical Judgement

If you want to talk to supervisor:

Hi Dr …. Is that a good time? … I’d like to seek your advice on my new patient….

• Investigations

2- Treatment Advices

• 5C (Explanation – Education – Reassuring – Sharing decision)

o Condition (Provisional diagnosis)

o Cause

o Commonality

o Clinical features

o Complications and consequences of not treating the disease

✓ Management would be started with 1- patient’s agenda (concern), 2-

Empathy and 3- reassuring

✓ Try to be culturally sensitive (aboriginals), use simple words with a

friendly manner.

✓ Sharing decision is important: how do you feel about that?... what is your
idea? …. It is recommended to …. (It is recommended to do more physical
activity during the day. How do you feel about that) Don’t patronize!!

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First, I would appreciate my patient's cooperation with me in history and physical examination.
Then I explain the nature of the disease in simple words and a friendly way and check the
understanding of the patient. And I also tell him about the other possible causes that we
should conduct some tests to rule out. I would be empathetic regarding my patient's concerns
and reassure him about my support and availability of the treatment. I also educate my
patient about the commonality, clinical features, and complications if it is left untreated. I
would double-check my patient's understanding repeatedly.

We can work out a management plan together. There are some things that you can do, and
there are some things that I can do for you as your doctor

After each paragraph, ask:

✓ Am I making sense?

✓ Are you following me?

✓ Are you with me?

✓ Do you have any question so far?

• Non-pharmacological management

o Advices:

✓ Symptom diary (to find any trigger) (if due)

✓ …

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o SNAP – T

✓ Smoking and Social Drugs

✓ Nutrition and Weight

✓ Alcohol and Caffeine

✓ Physical Activity and Sleep

✓ Advise adult patients to be active on most (preferably all) days of the

week

▪ Tranquility (YOGA – relaxation – mind-fullness)

• MR4S2

o Medication

o 4Rs: 2 Refs 2 Reds

✓ Reading materials

✓ Red flags

✓ Review Sessions

✓ Refer

o 2Ss

▪ Safety and Support:

▪ Vaccine, Screening, Prophylaxis and…

▪ We have some support services to give you a hand in care,

▪ Offer Aboriginal health worker at the end of the consultation

▪ Supervisor: If the patient is happy with the management plan, I will

doublecheck my management plan with my supervisor to confirm it.

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• FNA

o Family meeting

o Notifiable diseases

o Action and management plans and letters

▪ Action plan

▪ Advance care plan, Advance care directive

▪ mental health treatment plan

▪ GP management plan

▪ Team care arrangement

▪ Sick leave letter

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