Homeless Clinic Handbook

Forms

Seeing Your Patient

Basic Physical Exam

Follow-Up

Congratulations on your decision to participate in the University Utah School of Medicine Homeless Clinic Program. Each Saturday, the Fourth Street Clinic on 4^th South and 4^th West is run on a volunteer basis. Local physicians volunteer their time to oversee things as medical students see patients and largely run things for the day.

The benefits of participating at the clinic are numerous:

• This program is an excellent opportunity for medical students to gain clinical exposure, seeing patients and participating in the process of diagnosis and treatment.
• Students have the chance to provide a valuable service to the community.
• Students get to work side by side with local physicians.
• At the completion of the year, students who fulfill attendance requirements receive a certificate of service which goes in your permanent file and is included in your Dean’s Letter. This is an added plus when applying to residencies.

Understanding that new medical students may have a lot of questions about the art of seeing and treating patients, we have put together this handbook as a "crashcourse book o' basics". This book should provide you with answers to many questions about the homeless clinic, as well serve as a guide to the basics in providing excellent health care to this patient population.

Good Things to Know

Attendance Requirements

Participation at the homeless clinic involves the following commitment:

• You agree to attend at least two Saturdays during the quarter. You may attend more, according to need, but you must attend AT LEAST twice.

After you have signed the registration form, you’ll need to sign up for the weeks you plan on attending. Sign up at http://umed.med.utah.edu/get_involved/clubs/homelessclinic/attend/. We ask that no more than 8 students sign up per week. You'll notice that the weeks before tests fill up less quickly. This may be a great time to attend: you'll be able to see more patients!

Location and Directions

The homeless clinic is located on 4^th West and 4^th South (that’s 400 W and 400 S). The best way to get there is to go West along 3^rd South until you reach 4^th West. Turn South. You will pass underneath the freeway overpass. The clinic is on the right (West) side of the street just beyond the overpass. An entrance just South of the clinic leads to a fenced-off parking lot for our use.

Hours

When attending the clinic, you'll want to arrive a little before 9:00 AM. The doors open at 9:00 AM to patients, and you'll want a few minutes to get ready and to sign in. The sign-up sheet will always be at the front desk . It is important that you remember to sign in. Clinic doors close to patients at 12:00 noon, and you'll usually finish by 12:30 PM.

What to Bring

If you already have your own stethoscope, bring it--you'll need it and you may as well get accustomed to using your own. If you don’t have a stethoscope, the clinic does have a few, but they are not very sensitive. Also, if you'd like to bring your own ophthalmoscope, you’ll definitely have the chance to use it, but you won’t need to bring it as each room is equipped with ophthalmoscopes, blood pressure cuffs and otoscopes.

Also remember to wear your white lab coat and your nametag.

Professional Etiquette

Dress code

Looking professional is an important part of providing good patient care. Be sure to dress sharp. DO NOT wear your white coat. Wear slacks and a nice shirt. Jeans are not appropriate. For men, a tie is not recommended. Always remember your nametag.

Relations With Staff

One of the biggest advantages of attending the Homeless Clinic is the opportunity to see how health care professionals interact with one another and how medical students fit into this scheme. You'll have to figure out your place in this system sometime before 3^rd year and now is as good a time as ever. You will be presenting cases to physicians (See the section on Presenting), asking questions of PAs (physician assistants), and technicians, and working side-by-side with upperclassmen as well as residents. The main thing to remember is to treat everyone at the clinic with a great deal of respect regardless of their position and they in turn will not eat you for lunch, a guarantee that can't be made during 3^rd year rotations! Actually, everyone at the clinic is very friendly. They know we're just starting out and they take that into consideration. You'll normally be teamed up with a 2^nd or 3^rd year, so if you have questions, don't worry, you won't be alone.

Professionalism with Patients

Even though you're just getting started as a health care provider, it's important even at this stage of the game to be professional. This can be accomplished by respecting the patient. Respect their time. This may be an excellent chance to practice examination techniques, but don't perform a full neurological exam on someone with a chief complaint of a foot fungus, going on the erroneous assumption that the patient has nothing better to do all day. Most patients are very compliant and won't say anything because, hey, this is free health care for them; but a happy medium must be reached. This is a judgment call on your part. Using good judgment, take advantage of the opportunity to do physical examinations. A good rule of thumb is to always ask the patient if they have time for you to perform an examination even though it is not related to their chief complaint. Little things like how you dress, avoiding slang, and addressing the patient with confidence can also help portray professionalism. When seeing patients of the opposite sex, be sure to always have a chaperone present.

It's important not to be critical or judgmental about a patient's behavior. You'll be seeing a lot of drug abusers and treating problems secondary to this problem. We're there to treat the patient, not to preach to them. It's one thing to recommend to a patient that they need to quit doing harmful drugs; it's another to berate them for a behavior they already know is harmful.

The most important thing that you can know about the homeless culture is that they are not all that different from you. Most medical students get financial aid to pay for everything from tuition and $100 textbooks (ugh!) to The Police’s new "Classics" CD. We get that money because somebody has faith in us that we will pay it back. What if that trust were gone? Not only that trust, but the support of family and friends that surround you and could help you. A sobering fact to keep in mind is that the net worth of the average medical student is lower than that of the average homeless person (most homeless people don’t have much debt). So why are they homeless and you’re not? Most of it has to do with earning potential, job stability, a lack of affordable housing in Utah, and sometimes personal characteristics.

Lack of income is a major problem for the homeless. The average wage of the homeless culture in Utah is about $70.50/month. Most are employed (60%) because of the favorable job market and low unemployment but not at wages high enough to get into housing. Still, many of the homeless quickly find better jobs and move on. The number of people who are homeless at some point during a given year is almost 10 times higher than the number of people who are homeless for the entire year - turnover is very high. What usually happens is that a given individual who has an apartment suddenly loses their job and has no savings. Apartment owners fear losing rent from someone who is barely scraping by and evict their tenants. Now the evicted individual must find a job without being able to write down a permanent residence and get an apartment without being able to write down a place of employment - not an easy thing to do. One survey found that to get into 52% of the federally assisted low income housing, one needed to meet a minimum income requirement which was usually two to three times the rent! Still, most people are able to do it in a few months time. The problem can be compounded by having a family to support.

The housing market in Utah is actually quite good…if you’re selling. Utah’s housing market inflation has outpaced the national average consistently for the past 6-7 years. In 1994, Ogden reported an 8.6% increase in housing costs (compare that to the 1-2% rise in cost of living nationally due to inflation and you can begin to see why affordable housing is lacking in Utah). Vacancy rates in Utah have fallen from 20% in 1986 to about 4 % in 1996 (landlords with waiting lists of people to get into apartments don’t have much of an incentive to lower the rent). Most of the homeless population could afford to pay $150-$200/month for subsidized housing, but there’s not enough such housing available.

The last reason for homelessness has to do with personal characteristics. This doesn’t mean that all homeless people have tweaked personalities, but there is a defined percentage that do. This is this segment of the homeless population that tends to remain homeless for longer periods of time. They consist mostly of the mentally ill or drug and alcohol abusers. Many of these people end up homeless because of circumstances they can’t control without some form of help. Currently 30% of the homeless population is considered to be mentally challenged in some form or other and efforts are being made to help these individuals. Richard Lamb explained the huge amount of mentally ill within the homeless population in a report titled Homelessness: "It is my feeling, however, that problems such as homelessness and criminalization of the mentally ill are not the result of deinstitutionalization per se but rather of the way deinstitutionalization has been implemented. A lack of understanding of the needs of the chronically mentally ill, plus the unplanned discharge of hundreds of thousands of mentally ill residents of state hospitals into inadequately prepared communities, added up to disaster." It is estimated that up to 40% of the homeless population suffer from alcohol abuse and 10-20% suffer from some form of drug abuse (it should be noted that many individuals become abusers of drugs and alcohol after becoming homeless).

The following is a list of risk factors that might lead to homelessness:

The most common illnesses that affect the homeless are infections and injuries. For children, this consists of respiratory problems and ear and eye complaints. Common complaints among adults include acute respiratory illness, acute and chronic musculoskeletal disorders, dermatological conditions, cardiovascular problems, podiatric problems, substance abuse problems, and lacerations/abrasions. Tuberculosis is 25 to 100 times more prevalent in the homeless population which amounts for about half of the total cases seen in Utah every year.

A recent survey evaluated the homeless’ own perceptions about their health. 71.6% of respondents said that they felt they were in good health, 22.6% said they had not been sick at all in the past year, 35.1% said they had been sick once within the past year, 25.0% said they had been sick three or more times, and 28.7% said that they had a serious or life-threatening illness within the past year. 31.5% of respondents indicated having a current chronic illness. Interestingly, a unique section of the younger population (in their 20’s) tended to get sick more often than any other segment of the homeless. There was no statistical difference between men and women’s health. Having some form of employment correlated highly with better health. Most of the women surveyed (63.9%) had access to some form of pre-natal care.

Anyone who has been down to the Homeless Clinic can tell you how sincerely grateful most patients are to receive help. Most realize that they might have to wait a while and they might get poked by a few medical students, and most are very patient about it (they’re actually a lot more patient than most of the people physician’s see in practice). The homeless are wonderful people. Everyone runs into "that one case" about the man chasing Dr. X down the hall with a syringe, but the fact is that if you love the people, they’ll love you back. On a final note, the following is what a group of homeless youths said to the rest of Utah:

"I really need your help."
"I hope someone cares enough about my needs."
"Help the kids out there on the street."
"It’s almost impossible to survive while waiting for food stamps.
"Time is the killer."
"The depression is bad."
"Help the ones that want help for themselves and hope the others come too."
"A lot of us need help getting by without getting involved in the drug scene."
"Let the average person know we are not hoods - we are not criminals or bad people - just unfortunate."

Most of this information comes from a block grant called the Consolidated Plan. It is available from the state from the Department ofCommunity and Economic Development, Division of Community Development. A copy may be available at the Homeless Clinic.

As you work at the Fourth Street Clinic, you’ll encounter several forms that you’ll want to be familiar with. Examples of these forms are given on the following pages. (In addition, there are other forms used by the regular staff which may be included in your patient’s charts. You do not need to know how to fill these out, so examples of them have not been included.) Those forms with which you will be dealing include the following:

• Intake form
• SOAP/progress notes
• Blue Problem List (stays in chart)
• Prescription form
• Referral form
• Lab form
• Injection log

How forms are used (overview)

Intake forms (a.k.a. long forms) are initially filled out by the staff receptionists in the waiting room. They fill out the top part of the form which deals with insurance and address information. The receptionist then pulls the patient’s chart, clips the intake form to the front of the chart and places it in a pile on the clinic counter. You then take the chart on top of the pile and pick up two copies of the Xeroxed SOAP/Progress notes (also on the counter.) One SOAP/Progress note is used to record the patient's vitals and to take notes during your history and initial examination (kind of a rough draft-type thing). After you have "presented" to the attending physician, and completed the examination and treatment, you write up your "soap note" on the second SOAP/Progress note. Then you complete the Intake Form. You sign both the final SOAP/Progress note and the intake form and take them to the attending for signatures before returning them to the manager at the counter. At that point, you are done and ready to grab the charts for a new patient. Be sure that the manager has checked all your forms before you leave for the day.

If that brief run-through of the forms made your head spin, don’t worry about it: it will all make sense after having gone through the process once. The most important thing to remember is to have a manager check over your forms before you leave for the day.

Intake form

IMPORTANT: Never throw away an intake form, even if you make a mistake or the patient leaves prior to completion of the examination. The forms are numbered consecutively and must all be accounted for. If a blatant mistake is made or the patient leaves, write "VOID" across the form and submit it with the patient's chart.

The top part of the form (filled out by the receptionist) includes basic information such as name, birth date, social security number, etc. The receptionist will also have asked questions relating to the patient's use of alcohol/drugs, whether or not they are employed, and where they are currently residing. In the upper left hand corner of the form is listed the patient's chief complaint (CC), or why they have come to the clinic that day.

The rest of the form (filled out by you) needs to be completed in eight areas (see example form on the following pages.)

• You need to check a diagnosis of those listed. If your diagnosis is not among those listed, write it in under "Dx (diagnosis) unlisted." If you have more than one diagnosis, prioritize them (1, 2, 3, etc.)
• You need to decide if the "Hx (history)/Exam" was "problem focused, expanded, detailed, or comprehensive" and if the "Decision" was "straight, low complex, moderate complex, or high." This decision is somewhat ambiguous, and attendings, managers or staff can assist you.
• If you requested that the patient come back for a check-up, circle "Y" by "follow-up indicated."
• If you wrote a referral, this must be listed under "Referral."
• If you gave sample meds, check "Sample Meds Given" and note what was given, the dosage given, and how much was given. This can be written in the margin of "Sample Meds Given." If you gave supplies, check "Supplies Given" and indicate what was dispensed.
• If you wrote a prescription, the Rx (prescription) number must be given. This is the number in red on the prescription form.
• If you did any lab, injection, or procedure, this must be checked where appropriate.
• You and the attending must both sign the bottom line of the form.

Remember to grab two of these before you call the patient back from the waiting room. The first note is your scratch paper to record vitals, take notes during the history, etc. The second note is for the final SOAP Note of the patient's visit (see example form.) The following needs to be completed:
 

• Be sure to copy the vitals from your first note. For blood pressure (BP), record whether the patient was standing, sitting, or lying down, and whether the right or left arm was used. Also, make note of respiratory rate (RR), heart rate (HR), and temperature (T).
• The patient's name, sex, race, and birth date (DOB) are recorded.
• The "soap note" will take up the majority of the page, with signatures at the bottom.
• Be sure to include the date in the upper right-hand corner.

We have currently been told not to fill this out, but to be familiar with it, a copy has been included. This sheet is blue and covers the yellow copies of past intake forms bound to the left side of the chart. Ideally, this sheet should reflect a summary of past visits.

Prescription form

These can be found in the attendings' room and should only be filled out by request of the attending. These normally will only be filled out in the case that sample meds are not available. The form has three copies. The pink and yellow copies of the form go to the patient, and the white copy is returned to the manager with the completed intake and chart when the patient's visit is over. The following must be completed:
 

• The date, patient's name, DOB, and diagnosis.
• The name, dosage, and how much of the medicine should be dispensed is recorded, along with instructions for use. BID means twice daily, TID is three times daily, QID is four times daily. ("Rx charge" is of no concern to us and should be left blank.) See the appendix for common abbreviations.
• Always check "generic equivalent may be substituted."
• Be sure to put a line through unused lines on the prescription pad to prohibit patients' adding drugs to the prescription.
• The attending must sign this form.
• The red Rx number must go on the intake form.

There are two referral forms, examples of which follow. One is entitled "WHHP Care Coordination Request Form" and is used to schedule an appointment through the care coordinator of the clinic. This form needs to be left on the desk of the care coordinator to ensure scheduling of the referral. The other is a referral form to send a patient to the ER. Both forms need to be filled out under supervision of the staff provider at the clinic.

Lab form

The only labs you may be doing are a urine pregnancy test, a urine analysis, and a finger stick/glucose test (See page 14 for instructions on doing these labs). The completion of these labs must be recorded on the lab form where appropriate (1). Be sure to include the patient's name and chart number, and the date (2). (3) Under "LAB," initial if you performed the lab. The attending initials under "PROVIDER." "RECORDS" is left blank. Be sure to also check the intake form where appropriate.

Injection Log

Any injection given (under supervision of the attending) must be recorded in the injection log. The form is mostly self-explanatory. The "Lot #" of each drug is listed on the bottle used.

The Waiting Room

When a patient enters the homeless clinic, they are instructed to "sign-in" on a sign-up sheet at the front desk. After this is done, an intake form (see Forms section) is completed on each patient by front desk personnel. Next, the patient’s chart is pulled if the patient has been to the clinic before or put together from scratch if the patient has not. Although students are not allowed to complete the intake forms, you can save the front desk some time if you volunteer to pull some charts or make them up. Stored charts are located in the room immediately behind the front desk in giant rolling filing walls. Yes, you may play with them, but try to limit yourself to 5 min. as there will be many other students who would like to play with the rolling wall files. Intake forms will be placed inside the patient’s chart and placed in a stack on the front clinic desk.

The Call Back

Before you can call the patient back, you must be sure you have done the following:

• Find a vacant room and flip the blank page located outside the door so that is reads "with patient".
• Quickly read over the patient’s chart to review the history. When was the last visit? What treatment has been provided in the recent past?

Temperature

Before taking the patient back to the examination room, you will record temperature and weight. Thermometers are located on the main clinic desk. Temperatures are taken on the tympanum with a digital thermometer. Slide a plastic hood onto the thermometer until you hear it snap. Next, place the thermometer inside the ear far enough that a reading from the tympanum can be taken (this does not mean that the thermometer needs to touch the tympanum). Push the blue button on the right side of the back of the thermometer (not the big one on the back). A digital reading will appear on the display. Remove the plastic hood by holding the thermometer over a garbage can and pushing the large blue button in the middle of the back of the thermometer. Try to be aware of any extra auditory discomfort that the patient might have before taking the temperature (e.g. if a patient’s right ear is infected, take the temperature in the left ear). This should not be a difficult procedure. Practice this on a fellow student before trying it out on a patient (you can try to practice on one of the attendings and you get a free doughnut if they let you). Unfortunately, we do not take rectal temperatures on adults at the homeless clinic.

Weight

Weight is measured with the scale located just inside the waiting room. Be sure to remove all heavy clothing before weighing them and be sure when you ask the patient their previous weight (for comparison purposes). A dramatic change in weight can mean some type of pathology or that the patient on some really great weight loss program. If you need instructions on how to operate the scale, please leave the clinic right now.

Height

The patient’s height should be measured if it is their first visit to the clinic. Once it has been recorded in the chart, we can assume that their height will remain the same, and it shouldn’t be measured again.

Vitals

A word about vitals. A long time ago someone decided that heart rate, blood pressure, and respiratory rate were really, really, really important (hence the name vitals). Let it be said that whoever came up with this gross categorization was right on! Vitals are vital! Do not skip vitals because someone comes in for a prescription refill (do, however skip the rest of the physical unless otherwise indicated). Do not skip vitals when someone has a small scratch and needs a Band-Aid. In other words, never skip vitals!

Heart Rate:

Urine Dip

The SOAP Note

You'll find that excellent communication skills are part of the foundation of every good health care provider. It is essential to be able to present a large body of information in a clear, concise manner. For this reason, when documenting a patient's visit, providers follow a format known as the SOAP note. You'll be writing literally thousands of these over the course of your career.

SOAP is an acronym for Subjective, Objective, Assessment, and Plan. After taking the patient's history and asking all the pertinent questions, find a comfortable spot in the lounge and take a few minutes to write the SOAP note.

The SOAP/Progress Notes form has the following information on the top: today's date, patient name, DOB, BP, Temp, Heart Rate (HR), Respiratory Rate (RR). The rest is a blank, lined sheet. Along the left side, write a large "S", "O", "A", and "P". Here's what to include after each.

Subjective: Under "S", you write the patient's story, normally in his or her own words. You might write something like, "I've had a dull burning ache in my side since last week", or "I've got a cough that won't go away". This is also a good place to include relevant past medical history.

Objective: "O". This is the place to put everything that can be observed, measured, put into numbers, or is just solid fact. A good way to start with "O" is, "Patient is a 35 year old Caucasian male…" Include in this section the results of any exam performed, labs run, or procedures conducted. Examples include findings of lung ausculations, palpations of the abdomen, heart sounds, etc.

Assessment: "A". Your conclusions about the findings. What is your diagnosis? For example, "Irritable bowel syndrome", or "second degree burns on dorsal surface of right foot". If a patient's complaints are multiple, and you assess multiple problems, number each one. For example:

• Emphysema due to smoking.
• Infected abscess on right thigh.
• Pernicious toe-jam on right foot.

• t. given albuterol inhaler to be used as required.
• Abscess cleansed using sterile technique, packed wet-to-dry, and covered with bandage. Pt. to return every 2 days to change dressing.
• Pt. told to wash feet every so often.

Keep in mind that the purpose of the SOAP note is to clearly and concisely document all information pertinent to that patient's visit. Each time that patient returns, the provider seeing him or her that day will quickly review the chart and will want to be able to quickly and easily assimilate all the important information about the previous visit. That means write only the important information, but ALL of the important information. Details are important. Writing an effective SOAP note will not only help providers seeing this patient in the future, it will also help you get your thoughts organized for the presenting of your patient to the attending.

Once you've organized all the information on your patient, you'll present it to a physician so he/she can help you with the diagnosis. Chances are, you won't know exactly what's wrong with the patient, and that's perfectly OK at this stage in the game. That means you probably won't be able to finish your SOAP note before presenting. That's OK too. Just do as much as you can; you can at least get the S and O. The doctor may have to help with the A and P.

Presenting

Just as writing a concise SOAP note is important, making a clear, concise presentation is also all-important. Before you present for the first time, you may want to practice once or twice with a second-year. It's not unforgivable to tell the doctor that this is your first time presenting and you're really not sure what you're doing at all. (P.S. This would be a bad thing to do during your 3^rd year, so take advantage of it now.)

When presenting, start out by saying, "Patient is a 27 year old African-American female presenting with a chief complaint of________." You've just covered "S". Move on to "O". As concisely as possible, present the relevant findings of your exams and history. When you're done, the doctor may ask you a few questions. Answer to the best of your ability, and hey, why not take a stab at a diagnosis. If you miss the mark, the doctor will make sure the correct diagnosis is eventually made.

After your presentation, the doctor will want to see the patient with you. They will typically ask the patient a lot of the same questions you did. They'll arrive at a diagnosis and, together, you'll work out a plan for treatment. After implementing the treatment, take a few minutes to complete the SOAP note, and give it to the doctor for approval. They'll sign it and you're done!

At the bottom of the sheet, be sure to sign the sheet, with "MSI" after your name.

NOTE: (The information in this section and the section "The Basic Physical Exam" is included in a more condesed, concise, and xeroxable form in the appendix labeled "Cards")

Taking a patient history is an art that you will be developing during the next four years. The taking of a complete and accurate history is an important step in arriving at a precise diagnosis. In fact, having taken a thorough medical history, a physician can arrive at the correct diagnosis 75% of the time. That’s without ANY labwork! Anytime a patient comes into the clinic for the first time, you should take a complete medical history (i.e., one that includes all of the components listed below.) If the patient comes to the clinic frequently, or has a chart already, the history can be restricted to the problem at hand.

The overall history includes the following components:

• Chief complaint (CC)
• History of Present Illness (HPI)
• Past History (Past Hx)
• Social (and Sexual) History (Social Hx)
• Family History (Family Hx)
• Review of Systems, where appropriate

The CC is the principal symptom that led the patient to seek treatment on a particular day, and its duration. Examples include: "pain in my stomach of two days duration", or "chills and fever for the last 24 hours".

The History of the Present Illness

The HPI focuses in more detail on the CC and the current medical situation. This is recorded in chronological order and should be in the patient's own words as much as possible. The HPI should include the following information about the medical problem:

• anatomical location, including radiation
• quality, or what it is like
• quantity
• onset and timing
• aggravating or alleviating factors
• functional impact of the problem
• associated symptoms
• previous occurance

The Past Hx

This is intended to give a background of information which might provide some clues to solving present medical problems. The Past Hx includes the following:

• general health
• childhood illness, including surgeries or hospitalizations
• adult illness, including surgeries or hospitalizations
• accidents or injuries
• allergies
• immunizations, including DPT, MMR, Hep B, Flu, Pneumonia
• health maintenance, including pap smear and mammograms, cholesterol testing, etc.
• use of alcohol, illicit drugs, caffeine
• transfusions
• current medications

This includes information regarding lifestyle, which can also provide clues for diagnosis. Questions should be asked regarding:

• birthplace, subsequent residencies, and current living situation
• education
• occupational history, including exposure to toxic substances
• marital status and history, current family structure
• travel
• diet and exercise
• sleep habits
• pets
• sexual history, including number of sexual partners and gender of partners, past and present
• all stressors, including financial hardship, marital problems, etc.

The Family Hx provides information regarding other members of the family. This information might give clues into illnesses which have elements of inheritance. The areas which should be included in the Family Hx are:

• close relatives' age and health if living, cause and age of death if deceased
• illness in the family similar to patient's
• common disease known to be partially heritable, e.g., diabetes, hypertension, allergies, cancer, arthritis, heart or kidney disease, asthma, psychiatric problems

The review of systems is a detailed inquiry into all physiological systems of the body. Again, this extensive review is mostly done in its entirety only when the physician needs a thorough introduction to a new patient. Usually, you will be seeing patients who have already been to the clinic several times, so you may ask briefly about all systems, but ask extensively only about the system(s) pertaining to the patient's medical problem(s). Review of Systems includes:

• Constitutional Symptoms
• Skin
• Head, Eyes, Ears, Nose, Throat (HEENT)
• Respiratory
• Cardiac
• Breasts
• Gastrointestinal (GI)
• Genitourinary (GU)
• Neurological
• Musculoskeletal
• Psychiatric
• Hematologic
• Endocrine

Skin: texture, rashes, itching, hives, sores, eczema, bruising, jaundice, pallor, cyanosis, change in color, dryness, lumps or growths, hair loss, hair dyes, abnormalities of nails, status of moles

HEENT:

Cardiac: chest pain or discomfort, palpitations, heart trouble, high blood pressure, rheumatic fever, heart murmurs, orthopnea (discomfort in breathing), dyspnea (shortness of breath), paroxysmal (sudden) nocturnal dyspnea, pedal edema, claudication (limping) or pain in legs when walking, varicose veins, coldness of extremities, loss of hair on legs, discoloration of extremities, past myocardial infarction, past electrocardiogram or other test results

Breasts: lumps, nipple discharge, pain or discomfort, tenderness, self-exam

Gastrointestinal: appetite, nausea, vomiting, hematemesis (vomiting blood), flatulence, regurgitation, indigestion, dysphagia (difficulty swallowing), abdominal pain, change in abdominal size, heartburn, jaundice, hepatitis, food intolerance, excess hunger or thirst, bowel movements (frequency, diarrhea, constipation, change in appearance), melena (black stool due to blood), hemorrhoids, rectal bleeding, hernia, Hx of liver or gallbladder disease

Genitourinary: frequency and urgency of urination, polyuria (excess urine output), dysuria, nocturia, incontinence, difficulty starting or stopping stream, change in color or clarity of urine, burning or pain on urination, hematuria (blood in urine), libido, Hx of venereal or kidney disease, [men] testicular pain, change in shape or size, hernias, discharge from or sores on penis, [women] menstrual periods (age of onset, regularity and length of cycle, duration and amount of flow), dysmenorrhea, intermenstrual bleeding, bleeding between periods or after intercourse, premenstrual tension, date of last period, vaginal discharge or itching, sores or lumps, use of contraceptives, parity (pregnancies, deliveries, still-births, living children), age of menopause, postmenopausal bleeding, last pap smear and result, Hx of breast or uterine or cervical cancer, exposure to DES (diethylstilbestrol) if born before 1971

Neurological: lightheadedness, vertigo, headache, syncope (loss of consciousness), convulsions, weakness, unsteadiness of gait, paralysis, paresthesias (numbing or tingling), loss of sensation, abnormalities of speech, tremors, loss of memory, disorientation, Hx of strokes

Musculoskeletal: muscle or joint pain or stiffness, muscle wasting, swelling or redness, limitation of motion, deformities, arthritis, gout, backache (location and symptoms)

Psychiatric: nervousness, tension, mood, depression, Hx of nervous breakdown, hallucinations, delusions, loss of memory or confusion, change in personality, sleeping patterns

Hematologic: pallor, anemia, transfusions, jaundice, enlarged lymph nodes, enlarged spleen, excess bruising or bleeding

Endocrine: goiter, Hx of thyroid trouble or diabetes, heat or cold intolerance, excess sweating, exopthalmos (bulging eyes), voice change, excess hunger or thirst, polyuria (excess urine output), change in body weight or contour, libido, hair distribution and amount

Once the complete history has been taken, you will want to do an initial, basic physical exam before presenting to the attending. The full exam includes all systems mentioned in the review of systems; however, at the clinic, you will be performing only the parts of the exam relevant to your patient. In other words, if someone comes in with a laceration on their foot, don’t do a neurological exam on them! To put the question in everyone’s mind to rest: no, you will not be doing many rectal exams at the clinic.

What follows is a description of a full physical exam. You may use this as a reference. Look up that part of the exam that would be useful to your patient’s problem. Any abnormal findings should be recorded. Necessarily, all abnormal possibilities have not been listed.

Patient is sitting, facing physician.

1) General appearance--obese or abnormally thin, acutely or chronically ill, sweating or otherwise uncomfortable, state of nutrition, deformities, appearance suggestive of specific disease

2) Vital signs

• blood pressure (make sure patient is resting arm comfortably on armrest of chair or table)
• radial pulse (rate and quality)
• respiratory rate (and character of breathing)
• temperature (taken at front counter of clinic)

4) Head--Inspect for scars, open sores. Palpate nodes.

5) Eyes

• Inspect sclera, conjunctiva, cornea, iris.
• Check pupillary reaction to light.
• Check visual acuity with pocket screener.
• Check extraocular movements (e.g., have them follow your fingers.) Look for saccades or nystagmus (jerky movements of eyes.)
• Do funduscopic exam with ophthalmoscope. Check for red reflex, arteries and veins, fovea.

• Inspect auricle and pinna of ear.
• Inspect external ear and tympanic membrane. Look for light reflex, color, bulging and outline of ossicles.
• Note auditory acuity.

• Inspect external nose.
• Inspect septum and turbinate with otoscope.
• Percuss sinuses. Listen for resonance or lack thereof.

• Inspect lips, mucosa, gums, teeth, tonsils, uvula, tongue and pharynx (remove dentures if present.)
• Test gag reflex.
• Have patient stick out tongue, clench teeth, smile, and open their mouth.

9) Neck

• Check range of motion.
• Have patient shrug shoulders.
• Palpate thyroid gland and trachea.
• Palpate submandibular, cervical and posterior auricular lymph nodes.
• Note quality of voice.

10) Chest

• Have patient breathe deeply. Check for symmetry of expansion.
• Palpate axillary and supraclavicular lymph nodes.
• Percuss spine, costovertebral angles, and lung fields posteriorly. Check for symmetry in auscultation.
• Auscultate posteriorly over the apices and bases, and auscultate anteriorly over the upper lobes, the right middle lobe and the lingula. Listen for abnormal sounds.

Abnormal lung sounds:

• Discontinuous sounds
• Crackles--intermittent, nonmusical, briefs pops of sound
• Rubs (may also sound continuous)--similar to crackles, but sounds more like grating than opping
• Continuous sounds

• Ronchi--low-pitched, with snoring quality
• Wheezes--high-pitched, with hissing or shrill quality

11) Heart

• Inspect neck veins.
• Palpate and listen over each carotid artery. Check for simultaneous extremity pulses (femoral, popliteal, posterior tibial, dorsalis pedis, brachial.)
• Inspect and palpate the precordium (lower thorax), right and left 2nd intercostal spaces, apex of heart (left 5th intercostal space, the left ventricular area), and left sternal border (right ventricular area.)
• Auscultate the entire precordium, pressing firmly with the diaphragm of the stethoscope.
• Auscultate over right and left 2nd intercostal spaces, subxiphoid area, apex of heart (left 5th intercostal space), and left sternal border with the diaphragm of the stethoscope.
• Auscultate with the bell of the stethoscope at the apex of the heart.

12) Breasts

• Inspect and palpate. Note any lumps, dimpling or nipple discharge. Check for symmetry.

• Inspect general appearance, including skin color.
• Auscultate over epigastrium and umbilicus for bowel sounds and bruits (fast, rushing sound of liquid.) Watch for excessive noise, absence of sound, pitch of sound, humming sound, or rubbing sound.
• Percuss upper and lower margins of liver, spleen, and abdominal wall.
• Palpate for liver, spleen, kidney, abdominal aorta. Note masses or tenderness.
• Check femoral pulses and lymph nodes.

• Inspect hands, arms, feet, and legs. Note any edema, clubbing, splinting hemorrhages, cyanosis. Check for capillary refill at nails.
• Palpate dorsalis pedis and posterior tibial pulses.
• Check plantar flexion reflex.

15) Neurological Examination

• Check gait. Have patient walk heel-to-toe 10 paces.
• Check sensation by response to pinprick, temperature change, vibration, light touch, proprioception (positional sense of body parts), two-point discrimination (patient can tell if they are being touched in two places or one.)
• Check cerebellar function. Have patient touch finger to nose repeatedly. Have patient run the heel of one foot down the shin of the other leg. Have patient pronate and supinate one hand as quickly as possible.
• Check other cranial nerves. Have patient wrinkle forehead. Have patient blink eyes.
• Perform Mental Status Exam. Have patient repeat three objects in five minutes, serial numbers in groups of threes and sevens, spell world backwards, name three presidents, interpret a proverb, complete three-part instruction (e.g., Take paper with right hand, fold it in half, place it on the floor.)

16) (Male) Genitalia (use glove)

• Inspect penis.
• Palpate testes.
• Check for inguinal hernia.

17) (Male) Rectum and Prostate (use lubricant)

• Inspect for hemorrhoids, fissure.
• Check sphincter tone.
• Palpate for rectal masses.
• Palpate prostate.

18) (Female) Pelvic exam

• Inspect external genitalia.
• Inspect vaginal vault with speculum.
• Obtain Pap smear and culture.
• Palpate vagina, cervix, uterus, and ovaries.
• Perform rectal examination.

Signatures

Signatures are one of the easiest yet often forgotten tasks involved with the homeless clinic. They are incredibly easy to obtain, but if forgotten, they can cause managers and other homeless clinic workers to run for the aspirin bottle. Medical students lack two small, yet important letters after their name which makes their legal accountability pretty much negligible (not, however absent). This is good for the medical students, but accountability is something that the homeless clinic records must have. Therefore, please make sure that your SOAP note and intake form are signed by a physician before turning them in. Each form should be signed at the bottom (there is an actual space indicated on the intake form).

Completion of Forms

If you are unsure about how to fill out a form properly, please consult the Forms section. After you have finished with the patient’s record, give it to one of the managers or place it in a pile at a location of the managers discretion. The managers will check over each patient’s records to be sure everything is correct. There are common mistakes (like forgetting to date the intake form) but none of them are serious as long as you don’t leave before your patient’s records are double checked (if you need to leave right away, please inform the managers so they can look over your patient’s records first).

Cleaning Rooms

All of the patient’s rooms should be clean when you arrive at the clinic. Keeping the rooms clean during the clinic can facilitate the final cleanup when the clinic closes. After finishing with a patient please do the following:

• Change the sign outside the door so that it does not indicate "With Patient".
• Replace the paper on the patient table by pulling it from the front. Place the used paper in the garbage.
• Place all sharp instruments or objects into the sharps container (a hard, red plastic container that should be in every room).
• Use the red biohazard garbage can for anything "yucky". An example would be gauze that is wet from something other than water, anything bloody, or excretions of any type. Please be aware that these red biohazard garbage bags are very expensive to dispose of. Therefore, please do not throw things away in these bags that are not truly biohazards (e.g., do not throw the used paper from the patient table in the biohazard bags).
• Clean all counters and floors if necessary (no, don’t go get a mop and ammonia, but a little straightening would be nice).
• Be sure and remove the hoods from the otoscopes and throw them away (not in the biohazard bags).

Generally, you should expect to be at the clinic until about 2:00 PM. Depending on how many patients need to be seen and how many medical students attend on any given day, you might leave as early as 1:00 PM or as late as 3:00 PM. If you need to leave early, no problem. The most important thing to remember when leaving the clinic is to let the managers know that you are going. That way, all of your patient’s records can be examined and checked before you leave. Be sure to sign the roll before leaving and please leave any pens or pencils that you grabbed during the day at the clinic.

Common Abbreviations

Common/Chronic Illnesses and Infectious Diseases

This section has been included to provide a very basic reference of the most common illnesses you’ll be seeing at the clinic. The book Griffith's Five-Minute Clinical Consult is available for reference at the clinic and is an excellent resource to confirm a probable diagnosis (good to use while waiting to see the attending!)

Diseases of HEENT (Head, Eyes, Ears, Nose, Throat)

• Otitis Externa--Inflammation of external auditory canal, usually bacterial
• Otitis Media--Inflammation of middle ear, usually bacterial, accompanied by viral

• Rhinitis--inflammation of nasal mucosa
• Allergic (hay fever)--due to airborne allergens, nasal turbinates appear pale
• Viral--due to virus, nasal turbinates appear red
• Pharyngitis--inflammation of pharynx (throat)
• Streptococcal--bacterial, most common pharyngitis
• Influenza (flu)--inflammation of nasal mucosa, pharynx, respiratory tract, caused by virus

• Upper Respiratory Infection (URI), acute--viral, often associated with nasal inflammation (common cold)
• Lower Respiratory Infection (LRI), acute--viral or bacterial
• Bronchitis, acute--inflammation of trachea, bronchi, and bronchioles
• Pneumonia--inflammation of lung, usually accompanied by fever, often follows URI
• Chronic Obstructive Pulmonary Disease (COPD)
• Emphysema--difficulty breathing due to destruction of lung alveoli
• Chronic Bronchitis--excess mucous secretion and persistent cough
• Asthma (allergic)--wheezing and/or coughing due to constriction of air passageways in the lung
• Tuberculosis (TB)--organisms are inhaled and then spread to multiple systems of the body, organisms can survive in a dormant state for many years

• Bacterial skin infections
• Cellulitis--infection of the dermis and subcutaneous tissue
• Impetigo--intraepidermal infection with papules (pimples)
• Abscesses--localized collection of purulent exudate (pus) caused by tissued destruction, often associated with swelling and inflammation
• Viral skin infections
• Warts--caused by human papilloma virus
• Chicken pox (Varicella)--caused by Varicella zoster virus
• Dermatitis--inflammation of skin
• Contact--cutaneous reaction to external substance
• Atopic (eczema)--cutaneous reaction due to internal causes

Gynecological infections, acute (female)

• Pelvic Inflammatory Disease (PID)--inflammation of uterus, fallopian tubes and ovaries due to spread of infection from lower genital tract, usually associated with abdominal pain and fever
• Cervicitis & vaginitis--inflammation of cervix and vagina
• Gonorrhea--caused by bacterial Neisseria gonorrhoeae (gonococcus)
• Chlamydia--caused by bacterial Chlamydia trachomatis, most common sexually transmitted disease in USA
• Urethritis (male)--inflammation of urethra
• Chlamydia--caused by bacterial Chlamydia trachomatis, most common sexually transmitted disease in USA
• Gonorrhea--caused by bacterial Neisseria gonorrhoeae (gonococcus)
• Urinary tract infections--caused by microorganisms, most frequently E.coli, most common in females

• Gastroenteritis--infection at any level of GI tract (gut)
• Diarrhea, acute or chronic--most common symptom of gastroenteritis
• Peptic Ulcer Disease--cause unknown but possibly of infective origin, common symptoms include pain associated with eating

• Diabetes Mellitus (DM)--prone to hyperglycemia and glucose intolerance due to insulin deficiency
• Hypertension--high blood pressure, multiple causes
• Coronary Artery Disease (CAD)--deposition of fatty plaques on the walls of arteries, limiting blood flow, cigarette smoking has a major causative effecct
• Depression--includes polar (depressive only) and bipolar (manic depressive) disorders, somewhat treatable with antidepressants

EnglishSpanish

abnormal = abnormal
abortion = el aborto
abscess = el absceso
accident = el accidente
ache = el dolor
addict = el adicto
affected = afectado(a)
afternoon = la tarde
again = otra vez
age = edad
alcohol = el alcohol
allergy = la alergia
always = siempre
anemia = la anemia
ankle = el tobillo
another = otro(a)
antibiotic = el antibiotico
appendix = el apendice
appetite = el apetito
appointment = la cita
arm = el brazo
arteries = las arterias
arthritis = el artritis
asthma = el asma
aunt = la tia
(to) awaken = despertar(se)
back = la espalda
bad (badly) = malo(a) (mal)
Bandaid = la curita
bathroom = el bano
bed = la cama
belly = la barriga, la panza, el vientre
(to) bend over = doblar
better = mejor
birth = el parto
birth control = control de la natalidad
bladder (urinary) = la vejiga
blanket = la colcha
blister = la ampolla
blood (in urine) = la sangre (en la orina)
blood cells = los globulos
blood pressure = la presion
bone = el hueso
(to be) born = nacer
brain = el cerebro
(to) break = quebrar
breast (breast feed) = el seno (dar el pecho)
(to) breathe = respirar
bronchioles = el bronquio
brother = el hermano
burn = la quemadura
chest = el pecho
chicken pox = la varicela
child = el nino(a), el nene(a)
chills = los escalofrios
chin = la barbilla
cholesterol = el colesterol
chronic = chronico
circulation = la circulacion
circumcision = la circuncision
clavicle = la clavicula
clinic = la clinica
clothing = la ropa
cold (temperature) = el frio
cold (health) = el resfriado
colon = el colon
comfortable = comodo(a)
condition = la condicion
condom = el condon
constipated, to be = estar alinado, estrenido
contagious = contagioso
contraceptive = anticonceptivo
convulsion = la convulsion
cortisone = la cortisona
cough = el tos
cousin = el primo (la prima)
cramps = los calambres
dangerous = peligroso(a)
daughter = hija
dead = muerto(a)
deaf = sordo(a)
(to) defecate = obrar
dehydration = deshidracion
depressed = deprimido(a)
diabetes = el diabetes
diagnosis = el diagnostico
diaper = el panal
diarrhea = la diarrea
diet = la dieta
difficulty swallowing = la dificultad al tragar
disease = la enfermedad
dizziness = los mareos
dizzy = mareado(a)
dose = la dosis
drug = la droga
dry = seco(a)
ear--outer/inner = la oreja/el oido
(to) eat = comer
elbow = el codo
emergency (ER) = emergencia (sala de emergencia)
environment = el ambiente
exam = el examen
(to) examine = examinar
exercise = los ejercicios
eye = el ojo
eyebrow = la ceja
face = la cara
fainting (to faint) = los desmayos (desmayar)
family = la familia
fast = rapido
fat = gordo(a)
father = el padre
fatigue = la fatiga
feces = los heces
(to) feel = sentir
fever = la fiebre, la calentura
finger = el dedo
first = primero(a)
fist = el puno
foot = el pie
forehead = la frente
fracture = la fractura
Friday = el viernes
friend = el amigo(a)
gall bladder = la vesicula biliar
gas = el flato
genitals  los genitales
(to) get better = mejorarse
(to) get well = sanarse
gonorrhea = la gonorrea
good (well) = bueno(a) (bien)
grandfather/mother = el abuelo/la abuela
grandson/daughter = el nieto/la nieta
green = verde
(to) grow = crecer
hair = el pelo
hand = la mano
happy = feliz
hard = duro(a)
hay fever = la fiebre de heno
head (headache) = la cabeza (el dolor de cabeza)
health = la salud
heart = el corazon
heat = el calor
hemorrhoids = las hemorroides
high = alto(a)
hip = la cadera
hives = las ronchas
hoarse = ronco(a)
hospital = el hospital
hot = caliente
how = como
how much = cuanto
hunger = el hambre
(to) hurt = doler
husband = el marido
ice = el hielo
infection = infeccion
ingrown (nail) = encarnado(a)
injection inyeccion
insomnia = el insomnio
intestine = el intestino
itch = el picazon
joint = la cojunctura
kidney = el rinon
knee = la rodilla
laxative = el laxante
leg = la pierna
lips = los labios
liquid = el liquido
(to) live = vivir
liver = el higado
(to) look at = mirar
(to) lose weight = bajar de peso, adelgazar
lotion = la locion
low = bajo(a)
lungs = los pulmones
malaria = el paludismo
malignant = maligno(a)
malnutrition = desnutricion
measles (German) = la sarampion (aleman)
medication = el medicamento
medicine = la medicina
menstruacion = la menstruacion
miscarriage = el aborto accidental
mole = el lunar
Monday = el lunes
morning = la manana
mother = la madre
mouth = la boca
mucous = la mucosa, el muco
mumps = las paperas
mute = mudo(a)
name = el nombre
nausea = la nausea, el asqueo
neck = el cuello
negative = negativo(a)
nerve = el nervio
nervous = nervioso(a)
night = la noche
normal = normal
nose = la nariz
nothing = nada
numb = adormecido(a)
occupation = la ocupacion
often = a menudo
opaque = opaco(a)
oral = oral, por la boca
ovary = el ovario
overweight = sobrepeso
pain (sharp pain) = el dolor (la punzada)
pale = palido(a)
pancreas = el pancreas
pants = los pantalones
pap smear = la prueba de cancer cervical
parasite = el parasito
patient (person) = el/la paciente
penis = el pene
perspiration = el sudor
phlegm = la flema
pill = la pastilla
pillow = almohada
poisonous = el venenoso(a)
positive = positivo(a)
pregnancy = el embarazo
prescription = la receta
problem = el problema
pulse = el pulso
question = la pregunta
rape = la violacion sexual
rapid = rapido(a)
rash = la erupcion, el sapullido
rectum = el recto
red = rojo(a)
(to) relax = relajar
respiration = la respiracion
(to) rest = descansar(se)
ribs = las costillas
sad = triste
sample = la muestra
sanitary napkin = la toalla sanitario
Saturday = el sabado
scar = la cicatriz
scrotum = el escroto
semen = el semen
serious = grave, serio(a)
sexual relations = relaciones sexuales
shirt = la camisa
shortness of breath = los ahogos, la falta de aire
shoulder = el hombro
shower = la ducha
sick = enfermo(a)
sickness = la enfermedad
sight = la vision
signature = la firma
sinusitis = el sinusitis
sister = la hermana
skirt = la falda
sleep = el sueno
(to) sleep = dormir
sling (bandage) = el cabestrillo
slow = lento(a)
(to) smoke (to stop smoking) = fumar (dejar de fumar)
(to) sneeze = estornudar
social worker = trabajadora social
sometimes = a veces
son = el hijo
specialist = el/la especialista
specimen = la muestra
speculum = el especulo
spinal column = la columna vertebral
spleen = el bazo
spouse = el esposo(a)
(to) sprain = torcer
stable = estable
sterile = esteril
stillbirth = el nacido muerto
(to) sting = picar
stomach = el estomago
(to) strain = forzar
student = el/la estudiante
stuffy (as in nose) = tapada
suicide = el suicidio
sunburned = quemado(a) del sol
Sunday = el domingo
suppository = el supositorio
surgery = la cirugia
suture = la puntada
swab = el hisopo
(to) swallow = tragar
sweat (cold sweat) = sudor (sudores frios)
(to) sweat = sudar
swollen = hinchado(a)
symptom = la sintoma
syphilis = la sifilis
syringe = la jeringa
syrup = la jarabe
table = la mesa
tablespoon = la cucharada
tablet = la tableta
(to) take = tomar
(to) take off clothing = quitarse la ropa
tampon = el tapon
tape = la cinta
teaspoon = la cucharadita
teeth = los dientes
temperature = la temperatura
test = el examen
testicle = el testiculo
tetanus = el tetano
thermometer = el termometro
thick = espeso(a)
thigh = el muslo
thin = delgado(a)
thing = la cosa
thirst = la sed
throat = la garganta
thumb = el pulgar
Thursday = el jueves
thyroid = la tiroide
tight = apretado(a)
tired = cansado(a)
toe = dedo del pie
tongue = la lengua
tonsils = las anginas, las amigdalas
(to) touch = tocar
towel = la toalla
trachea = la traquea
(to) translate = traducir
trauma = el traumatismo
treatment = el tratamiento
tremor = el temblor
tube = el tubo
tuberculosis = la tuberculosis
Tuesday = el martes
tumor = el tumor
ulcer = la ulcera
uncle = tio
uncomfortable = incomodo(a)
(to) understand = comprender, entender
unusual = raro(a)
(to) urinate = orinar
urine = la orina
uterus = el utero
vaccination = la vacunacion
vaccine = la vacuna, la immunizacion
vagina = la vagina
vaginal discharge = el desecho vaginal
veins = las venas
virus = el virus
vitamins = las vitaminas
vomit = el vomito, la basca
(to) vomit = vomitar, basquear
waist = la cintura
wart = la verruga
water = el agua
weak = debil
Wednesday = el miercoles
weight = el peso
what = que
when = cuando
where = donde
which = cual
white = blanco(a)
why = por que
wife = la esposa
worse = peor
wound = la herida
wrist = la muneca
x-ray = la radiografia
yellow = amarillo(a)