What is the most important minute of your 15 minutes patient encounter? Any guesses? In my opinion the most important minute is the time spent outside the door! Why? Here are the reasons……… You are first exposed to a clue as to what case is on the other side of the door eg. abdominal pain. Remember you just know that the diagnosis has something to do with abdomen but you are still far from the list of DD's you have to come up with. Say you walk in and the patient points to the epigastric region,…..then your mind should go racing after Acute peptic ulcer disease, GERD, Duodenal ulcer, Acute pancreatitis, etc etc……..while if she sits with her hand on the Rt. Iliac fossa frowning, you probably would switch gears to think of Acute appendicitis, PID, torsion ovarian cyst, Endometriosis, Ileitis etc. Keep your options open ……..dont jump into conclusions until you get a thorough history! It is the time to organize your encounter - If you dont take the time now, you will not be able to coherently handle "the show" inside the room. Go over mentally or write down in your blue sheet, what are the possibilities you are thinking of, what systems you will be examining, how will you start the History of present illness, what DD's are you ruling out and recollect the name of the patient ……….before you put on that beautiful smile of yours and go on in…….KNOCK KNOCK……..it is show time! Make a mental note of what systems you are going to examine for eg. if it is LOC (loss of consciousness) you know you must examine CNS and CVS. If you barge in through the door without spending those vital seconds letting your brain pause, think and proceed – you are likely to end up just doing CNS. What are the likely chances that you would be thinking of examing CVS also when your brain is rushing through the History of Present illness, or trying to get the difficult patient to talk or console a crying patient…or get that long CNS history and exam done………let alone thinking about the clock ticking ! Make a list of DD's – Hey! it is just common sense to do that before you enter ……..you can always add more as you get more information from the patient. But without even having a couple of DD's in mind, how are you going to rule out or rule in the diagnosis for this patient while you take history of present illness. Dont forget your mnemonics - "How can I help you ? " ………Doc I have severe abdominal pain"…..uh…..uh…..hmmm………ahhhaaaaa…….Oh yes ………….When did it start ? …………Cut all the fumbling and mumbling ……..make the flow smooth by writing down your OPDFSC and PAMHUGS FOSS, WADES , FTLW, LIQORAAA…….The first few sentences can set the stage for the entire encounter. For the SP, it is a time (during the intial 10 sentences or so) to decide "Am I going to have a hard time understanding this doctor?" ……… SO, bottom line ………..Make a good impression in the initial greeting and if you have your mnemonics written……..you are well on your way for a smooth encounter!