Toronto Notes

You are seeing Mr. Ozuka, a patient undergoing chemotherapy for advanced prostate cancer. You have recently performed tests which show that his tumor has progressed to an incurable stage. You estimate his life expectancy to be approximately 6 months. You have called him into your office today in order to disclose the results of these tests.

History

• Determines current state of patient’s illness.
• Determines whether patient wants to hear the test results (patient would like to know results)
• Asks whether patient would like a family member or friend to be present
• Prepares patient before disclosing the results
• Provides diagnosis in a straightforward manner
• Conveys information with brevity and simplicity, avoids using medical jargon
• Establishes the impact of the news on the patient
• Asks about patient’s goals of care
• Asks patient about need for home support
• Asks patient about need for spiritual support
• Asks patient about need for financial support
• Inquires about patient’s end-of-life goals
• Uses appropriate tone of voice
• Uses appropriate level of language
• Uses appropriate body language
• Respects patient’s personal space
• Ensures patient’s privacy
• Displays empathy and provides emotional support to patient
• Handles patient’s questions well
• Ensures patient’s understanding of the information
• Allows patient to express concerns
• Summarizes interview

You are seeing Mr. Simmons, a patient of yours and the father of one your female patients, aged 16, from your general practice. He states that he recently found an empty pregnancy test container in his daughter’s trash can and wants speak to you about it. Take a focused history of his complaint.

History

• Inquires about the father’s concerns (father wants to know if his daughter is pregnant)
• Establishes context for the father’s concerns
• Acknowledges father’s concerns and reiterates his complaint
• Asserts that daughter’s autonomy supersedes father’s concerns
• Does not disclose details of daughter’s medical information
• Behaves calmly with patient
• Uses appropriate tone of voice
• Uses appropriate language with patient
• Uses appropriate body language
• Respects patient’s personal space
• Displays empathy
• Summarizes interview
• Handles patient’s questions well
• Ensures patient’s understanding of the situation
• Allows patient to express concerns
• Copes with patient’s interruptions
• Copes with patient’s aggressive tone and language
• Avoids overreacting

You are about to see Mrs. Chambers, a 71 year old woman, in your outpatient clinic. She was brought in today by her husband who is concerned that she’s becoming increasingly forgetful. Take a focused history related to her husband’s complaint and perform the MMSE on Mrs. Chambers.

History

• Asks patient if she concurs with husband’s concerns (she reluctantly agrees)
• Asks patient about forgetfulness in daily context (e.g. misplace keys, forgets to turn off stove)
• Asks about forgetfulness with dangerous house appliances (has previously left stove on)
• Asks about forgetfulness with medications
• Asks patient to personally assess her current daily function
• Ambulation (uses cane)
• Hygiene and dressing (independent)
• Eating, cooking
• Banking and shopping
• Housework
• Driving and transportation (still drives)
• Assesses for polypharmacy
• Visual acuity, dizziness
• Continence
• Falls (has fallen once)
• Arthritis
• Other past medical history
• Mood changes (patient’s mood is ‘so-so’)
• Alcohol use
• Social support outside of husband (has 2 adult children)
• Addresses patient’s reluctance to address her husband’s concerns

Mini Mental Status Examination

Introduces exam to patient and explains why they are performing the test

• (/5) Orientation to Place: Country, Province/State, City, building, floor
• (/5) Orientation to Time: year, season, month, day of the week, day
• (/3) Registration: Three naming prompts, asks to repeat back
• (/5) Attention: Asks to calculate serial 7s or spell WORLD backwards
• (/3) Recall: Repeating previously remembered words
• (/2) Language: Asks to name two objects of minimal difficulty
• (/1) Repetition: Asks patient to repeat a phrase back
• (/1) Complex Task: Draw intersecting pentagons for patient to copy
• (/3) Comprehension: Patient to follow three step command
• (/1) Writing: Patient writes sentences with proper syntax
• (/1) Reading: Patient obeys simple written command

Compiles total score, correctly interprets results, and conveys results to patients

You are about to see Mr. Oberman, a 23 year old male, in your outpatient clinic. He is a long time patient of yours. He comes to your office today because he’s becoming increasingly afraid to leave his house and he wants your help. He is very agitated. Please take a focused history of his complaint.

History

• Asks patient about content of fears (feels he’s being persecuted)
• Asks why he believes he’s persecuted
• Onset of beliefs
• How beliefs have changed his life, and what he has done about them
• Other delusions (denies delusions of grandeur, somatic, parasitosis, etc.)
• Visual hallucinations
• Auditory hallucinations
• Tactile hallucinations
• Ideas of reference
• Asks if patient has been harmed by anyone, or has harmed anyone
• Homicidal ideation
• Suicidal ideation
• Symptoms of depression
• Symptoms of mania
• Symptoms of anxiety
• Alcohol and Smoking history (quantity in pack-years)
• Other drug use, especially marijuana and hallucinogens
• Current medications and Allergies
• Occupational history
• Legal history
• Current social supports
• Family history of schizophrenia
• Family history of other psychiatric illnesses