In a perfect world, your physician would evaluate all of these things in a single visit. An empowered patient needs to team with their doctor to maximize the completeness of each visit.
Thanks to Rob Lambert, M.D. for the mind map
Things
that you can do to maximize your
visit
Winslow W. Murdoch, M.D.
Realize that you and your doctor have a limited amount of time to spend on goal setting and problem solving. Evaluating a given problem may take several visits and be done in a sequential way. Many conditions evolve over time, so even the best and brightest doctor and patient may not come up with the correct diagnosis or treatment plan at the first or even third visit. Keeping track of the "story" helps clarify and focus both parties. You will immeasurably help your doctor by relating your story in a way that they are trained to make a diagnosis. See my "History of Present Illness" Questionnaire at the end of this segment.
Other valuable tools include;
Keep a “personal health notebook,” or password protected computer file, where you write down any routine
questions you have for the doctor and take the notebook with you when you go to
your appointment.
Better yet, type your notes and ask your doctor’s office if you can
send/share the list via secure email or a patient portal prior to your visit.
If appropriate, Include some blood pressure readings, and make sure to note your range (highest and lowest) as well as average results
of home or community acquired blood pressure results.
Record your weight if this is pertinent to your medical history as
well.
If you have diabetes, and
are monitoring fasting or after meal blood glucose levels, include the ranges
(high and low fasting and after meal readings) and a guesstimate of averages of
the fasting and after meal numbers.
Keep a written record of your medical history and bring it to the
doctor’s office. They will really
appreciate it. They can copy it and put
it in your chart and you should take your copy back home with you.
Ideally, note all of your medication, food, and environmental allergies, all of your medications (see below) and each substantial medical or other problem on your list.
It is also very helpful if you are aware of how the problem is controlled and note this after the listed problem;
Well, not so well, or not at all well, etc.
Please, always bring a list of
current medications to every visit. The list should include things you take as
needed every once and a while, as well as any
and all vitamins, minerals and supplements.
Be sure to write the dosage and how often you take the medication and
supplements. If this is too hard to do,
bring a bag with all our medications and supplements with you. Prior to the
appointment, call the office and ask if you can arrive 30-60 minutes early
(depending on the size of your bag!) and have a clinical assistant to go
through your bag and make a list before your doctor’s appointment.
If you are presenting with a
new problem or concern, or a significant worsening of an existing problem, ask
if you can complete or at least review a triage sheet or questionnaire ahead of
your appointment. We maintain a list of these for the more common and serious
problems that we encounter on a daily or weekly basis. In addition, with new acute, or
complex chronic problems we often ask our patients to review and or complete a
“History of Present Illness” form that improves the accuracy of the visit
immensely.
Write down the names and
telephone #s of any specialists you have and take the notebook with you when
you go to see them.
If you have been hospitalized, gone to the emergency department or urgent care, or to another doctors office or had any lab, radiology or other studies done since you saw your doctor last, call ahead and make sure that your doctor has received results or communication from these outside sources prior to your visit.
History of Present Illness Questionnaire; pg 1 of 3- (in
context of personal and family history)
Name: Date:
When did the problem start?
Describe the onset of the process.
Have you had the problem before? If so, was there a diagnosis made? Was it
exactly the same- what is different now?
If there is pain, discomfort or an unusual feeling, where
exactly do you feel it- see diagram on last page- mark “x”s where you feel the sharpest strongest pain and
“o”s where it radiates or if it moves around etc.
Describe the quality of the pain or unusual feeling; sharp
dull cramping stabbing burning pressure squeezing pulling spasm etc and how it
changes etc;
Describe the severity of the pain or unusual feeling, how uncomfortable
is it (on a scale of 1-10, where 10 is the worst imaginable pain- screaming
with a hot poker in the eye) at its worst, best, on average and how long does it usually stay at the
different levels etc;
Describe the timing of the problem/pain- day or night? Wakes
from sleep? Keeps up all night like a tooth ache, constant intermittent? etc;
Describe any factors that seem to modify the pain- make it
better or worse and specify if they make it better or worse; eating pooping, peeing,
drinking, exertion, rest, certain activities (walking running hopping up and
down, postures (laying standing sitting bending twisting), sex, taking a deep
breath, bearing down, leaning forward, pushing on certain areas etc;
Describe how if any activities you are unable to do because
of the problem/pain- any disabilities due to the pain?
What if any treatments have you tried so far? Include
physical modalities like Heat Ice Rest Physical therapy acupuncture etc, over
the counter treatments or Rx treatments. Have any of them helped, what hasn’t
worked in the past?
What diagnostic tests (specific blood test, X ray, Cat Scan
MRI, Stress Test, internal scope procedure or surgical tests etc.) have been
done so far to evaluate the problem? Who ordered or did the tests? When were
they done and what if anything did they show?
Describe any associated signs or symptoms- fever chills
nausea sweats weight loss dizziness shortness of breath belly cramps skin
changes, swelling redness heat over area etc. that seem to come on along with
the problem if you have noticed any.
Form copyright Winslow W. Murdoch, MD
